bA-38Y7 Division,of Administrative Hearings of [LED vs. AHCA NO. 2002045449 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINIST AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, GENESIS ELDERCARE NATIONAL CENTERS, INC., D/B/A OAKWOOD CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against GENESIS ELDERCARE NATIONAL CENTERS, INC., D/B/A OAKWOOD CENTER (“Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is an action to assign a conditional license to Respondent, pursuant to Section 400.23(7), Florida Statutes (2001), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). A copy of the original conditional license is attached hereto as Exhibit “A” and incorporated herein by reference. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2001). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES S. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Respondent is a foreign corporation with a principal address of 101 E. State Street, Kennett Square, PA 19348. 7. Respondent operates a 120-bed skilled nursing facility located at 301 s. Bay Street, Eustis, Florida 32726. Respondent's facility is licensed by AHCA as a skilled nursing facility having been issued license number SNF1382096, certificate number 8767, with an effective date of June 19, 2002 and an expiration date of January 31, 2003. 8. Respondent’s facility is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT TI EFFECTIVE MAY 2, 2002, AHCA ASSIGNED A CONDITIONAL LICENSURE STATUS TO RESPONDENT BASED UPON THE DETERMINATION THAT RESPONDENT WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF A CLASS II DEFICIENCY DISCOVERED DURING THE COMPLAINT INVESTIGATION, WHICH BEGAN WITH A VISIT TO THE FACILITY ON JUNE 19, 2002; § 400.23(7), Fla. Stat. 9, AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. On or about June 19, 2002, AHCA began a complaint investigation at Respondent’s facility. A class II deficiency was cited against Respondent based on the findings below: Based on medical record review, staff interview, family interview, physician interview, interview with Adult Protective Service Investigator and Department of Children and Families District 13 Nurse Consultant and review of professional reports it was determined that one of four sampled residents, already under care for a pressure sore, failed to have due diligence taken to prevent, subsequently detect, and then care for avoidable bilateral pressure ulcers that developed on the heels. (Resident #3) Findings: Resident #3 was admitted to the facility on February 24, 2002 with a diagnosis of fractured hip and Alzheimer's dementia. The nursing admission assessment completed on February 24, 2002 identified a pressure sores on the coccyx and also noted, “heel soft- non-reddened." Interview with a facility nurse on June 19, 2002 at 4:45 p.m. and a nursing assistant on June 19, 2002 at 6 p.m. revealed that both recalled resident #3 wearing TED hose while in the facility. (TED hose is used to prevent blood clots) The nurse also stated the resident had TED hose on when he/she was admitted to the facility from the hospital on February 24, 2002. Interview with resident #3's family member on June 23, 2002 at 8:15 a.m. revealed the resident left the hospital on February 24, 2002 wearing TED hose. The family member also stated that he/she visited resident #3 daily in the nursing facility, sometimes twice a day, missing only two days, and resident #3, "always had TED hose on." ~ Review of the hospital record for resident #3 revealed nursing notes dated February 22 and 23, 2002, 8 a.m., documenting resident #3 wearing TED hose. Review of the nursing home record of resident #3 revealed no assessment or description of resident #3's heels after the initial nursing assessment of February 24, 2002 documented, "heel soft -non-reddened". A care plan developed March 6, 2002 for resident #3 called for assessing the skin daily. Interview with two facility nurses on June 19, 2002 at 6:08 p.m. revealed that nursing assistants assessed the skin twice a week on bath/shower days. For two weeks in March 2002, (March 4-10 and March 18-24), the nursing assistants' Customer Data Collection Sheets in the sections of skin condition were blank. No sheet was available from March 25-April 8, 2002. On April 8, 2002 (day before discharge) the Consumer Data Collection sheet documented O (open area) as they had done prior to March 4. Interview with a nurse on June 19, 2002 at 6:08 p.m. revealed this referred to the open area on the resident's coccyx which had been treated since admission. Further review of the care plan failed to reveal a approach for removal and application of the TED hose. No documentation was found to indicate that the physician had ordered the TED hose and that the facility had assessed the use of this device. The resident was discharged home from the nursing facility on April 9, 2002. Interview with a family member on June 23, 2002 at 8:15 a.m. revealed resident #3 was wearing TED hose when he/she left the nursing home. The TED hose was removed by the family member on April 11, 2002 in the morning. The family member stated the hose stuck to the resident's ankles, had stains on them and there was an odor. Resident #3's family physician was interviewed on June 27, 2002 at 2:45 p.m. He stated he saw resident #3 on April 11, 2002 at 8 p.m. He stated the resident had two posterior heel ulcers. He described what he saw thus, "the resident had third degree, full thickness skin loss on the heels. This was the product of two to three weeks, black skin was present. One and 1/2 inch x 1 inch black, dry adherent surface. Deep, red erythema was present." The physician stated, "this could not have happened in two days but was present for two to three weeks." Review of his report dated April 11, 2002 verified his statements. Review of a Florida Protective Services report pertaining to a visit made to resident #3 on April 13, 2002 at 3:15 p.m. revealed the following observation, "had Stage IV decubitus on both heels.” Interview with the investigator on June 20, 2002 at 8:10 a.m. confirmed these findings. Review of a report submitted by a Registered Nurse Consultant (contracted at that time with the Department of Children and Families, District 13), dated April 16, 2002 and interview with her on June 27, 2002 at 4 p.m. revealed that she spoke with resident #3's family physician on April 16, 2002. She documented in her report that the physician stated the condition of resident #3's heels occurred weeks prior to discharge. In the April 16, 2002 RN Consultant report was also documented that resident #3 had on that date bilateral, hard black eschar on the heels. Staging could not be determined due to the eschar. The RN documented that photos, taken on April 11, 2002, revealed yellow slough and eschar formation. Resident #3 failed to receive care to prevent bilateral pressure ulcers from developing despite staff being aware of an assessment dated February 24, 2002 documenting a soft heel. Additionally, facility staff failed to monitor resident #3 to reveal the presence of bilateral heel ulcers once they had developed, as indicated by their discovery after the resident left the facility. The resident was observed many times wearing TED hose yet there was no plan for their removal or application. Facility staff failed to obtain a physician's order for TED hose. As a result of the facility's negligence, the resident failed to receive necessary care and treatment to prevent avoidable physical harm. 11. Based on all of the foregoing, Respondent violated 42 CFR § 483.13(c) via Rule 59A-4.1288, Florida Administrative Code, by failing to have due diligence taken to prevent, subsequently detect if the condition could not be prevented, and then provide appropriate care and treatment for avoidable bilateral pressure ulcers that developed on both of a resident’s heels. i2. Pursuant to Section 400.23(8)(b), Florida Statutes, the foregoing is a class II deficiency because it compromises the residents’ ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 13. AHCA assigned a conditional licensure status to Respondent based upon the determination that the facility was not in substantial compliance with applicable laws and rules due to the presence of one (1) class II deficiency during a complaint investigation which began at the facility on June 19, 2002. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: a) Make actual and legal findings in favor of AHCA on Count I. b) Uphold the issuance of the conditional license with an effective date of 06/19/02, a copy of which is attached hereto as Exhibit “A”; and c) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, Respondent shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE Respondent, Genesis Eldercare National Centers, Inc., d/b/a Oakwood Center, hereby is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Jodi c. Page, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. GENESIS ELDERCARE NATIONAL CENTERS, INC., D/B/A OAKWOOD CENTER IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY AHCA. Respectfully submitted on this 15th day of August 2002. x oa RES Jodi C. Page, Fla. Bar. No. 0174629 2727 Mahan Drive, Ms#3 Tallahassee, Florida 32308 (850) 921-6362 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE — ie eee I HEREBY CERTIFY that the original Administrative Complaint and Exhibit “A” has been sent by U.S. Certified Mail Return Receipt Requested (return receipt #7106 4575 1294 2049 9115) to Oakwood Center, 301 8S. Bay Street, Eustis, Florida 32726, on this 15th day of August, 2002. AGENCY FOR HEALTH CARE ADMINISTRATION JO C. PAGE, are Fla. Bar. No. 0174629 2727 Mahan Drive, Ms#3 Tallahassee, Florida 32308 (850) 921-6362 (office) (850) 921-0158 (fax) COPIES TO: Elizabeth Dudek Deputy Secretary Managed Care and Health Quality Assurance Agency for Health Care Administration 2727 Mahan Drive, M.S. #9 Tallahassee, Florida 32308 (via interoffice mail) Exhibit “A” CONDITIONAL LICENSE License # SNF1382096; Certificate #8767 Effective Date: 6/19/02 Expiration Date: 1/31/03

Docket for Case No: 02-003849

Orders for Case No: 02-003849