STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Ane AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NOS. 2002045765 2002009431 vs. AGE INSTITUTE OF FLORIDA, INC. a/b/a CLEARWATER CENTER, Respondent. / oe ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “agency”}, by and through its undersigned counsel, and files this Administrative Complaint against AGE INSTITUTE OF FLORIDA, INC. D/B/A CLEARWATER CENTER (hereinafter somet imes referred to as “Clearwater”), pursuant to Chapter 400, Part II, and Sections 120.569, 120.57 and 120.60, Florida Statutes (2001), and alleges the following: NATURE OF THE ACTION 1. This is an action pursuant to Sections 400.022, 400.102(1) (da), 400.121 (1) (a), (3) (a) and (10), 400.23 (8) (a), and 400.19(3), Florida Statutes (2001): (a) to assess an administrative fine against Clearwater in the amount of $40,000.00 based on two (2) widespread class I deficiencies and one (1) isolated class I deficiency cited against Clearwater ata survey on or about June 29, 2002; (b) to assess an administrative fine against Clearwater in the amount of $22,500.00 based on one pattern class I deficiency and one isolated class I deficiency cited against Clearwater at a survey on or about January 28, 2002; (c) to impose a $6,000.00 six month survey cycle fee against Clearwater; (d) to revoke Clearwater’s license to operate a skilled nursing facility based on the fact that Clearwater was cited for two class I deficiencies arising from separate surveys or investigations within a 30-month period; and (e) to assess costs related to the investigation and prosecution of the case. 2. This administrative complaint incorporates by reference that certain Order of Immediate Moratorium dated July 2, 2002, a copy of which is attached hereto as Exhibit “A”. (AHCA Case Number 2002041531). The moratorium on new admissions was lifted by the Agency on or about July 10, 2002. JURISDICTION AND VENUE 3. The Agency 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 5. The Agency is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes (2001), and Chapter 59A-4, Florida Administrative Code. 6. Age Institute of Florida, Inc. is a Florida not for profit corporation with a principal address of 785 Fifth Avenue, Suite 4, Chambersburg, Pennsylvania 17201. 7. Clearwater operates a 120-bed nursing home located at 1270 Turner Street, Clearwater, Florida 33756. Clearwater is licensed as a skilled nursing facility having been issued license number SNF1091096. Clearwater is and was at all times material hereto a licensed facility under the licensing authority of the Agency, and is and was required to comply with all applicable rules and statutes. COUNT I CLEARWATER FAILED TO DEVELOP OR IMPLEMENT POLICIES OR PROCEDURES TO PROHIBIT THE MISTREATMENT OR NEGLECT OF RESIDENT #3. 42 C.F.R. § 483.13(c) Rule 59A-4.1288, Fla. Admin. Code (2001) § 400.022(1) (1), Fla. Stat. (2001) CLASS I DEFICIENCY ISOLATED 8. The Agency realleges and incorporates by reference paragraphs one (1) through seven (7) above as if fully set forth herein. 9. On or about June 29, 2002 the Agency conducted a survey at Clearwater. The Agency cited Clearwater for an isolated class I deficiency based on the findings below involving resident #3. RESIDENT #3 10. On or about March 27, 2002 resident #3 was admitted to Clearwater for antibiotic therapy related to a urinary tract infection complicated by methicillin resistant staphylococcus aureus. Resident #3 was expected to return home after completion of the antibiotic therapy. 11. On or about June 29, 2002 an Agency surveyor reviewed resident #3’s medical record. According to the record, resident #3 was alert, oriented, ambulatory, continent and talkative upon admission. The clinical record did not contain an advance directive in which the patient consents to the withholding or withdrawing of cardiopulmonary resuscitation (“CPR”). 12. On or about June 29, 2002 an Agency surveyor interviewed a certified nursing assistant (“CNA #1”) who worked the 3:00 p.m. to 11:00 p.m. shift on or about March 30, 2002. CNA #1 said he noticed the resident lying in the same position for over one hour. CNA #1 entered resident #3’s room and found the resident without a pulse and not breathing. CNA #1 said he notified the Registered Nurse Supervisor (“RNS”). CNA #1 said another CNA (“CNA #2”) and a licensed practical nurse (“LPN”) entered resident #3’s room. The LPN left the room to check resident #3’s clinical record located at the nurse’s station to determine whether the resident had any advance directives. The LPN returned to resident #3’s room and informed the RNS that resident #3 was a “full code” (needed full resuscitation) and to start CPR. CNA #1 stated that the RNS told the LPN to "finish passing her meds" as she "had it (the situation) covered." CNA #1 stated that the RNS instructed them not to touch the resident and then left the resident’s room for fifteen (15) to twenty (20) minutes. When the RNS returned to resident #3’s room she instructed the LPN to call 911 (Emergency Medical Services) . According to CNA #1, the RNS failed to perform CPR on resident #3 and failed to instruct other staff members to do so. 13. On or about June 29, 2002 an Agency surveyor interviewed CNA #2, who was assigned to care for resident #3. CNA #2 corroborated CNA #1’s statements outlined above. 14. On or about June 29, 2002 an Agency surveyor interviewed the RNS. During the interview, the RNS acknowledged that after resuscitation status was confirmed, CPR should have been administered to resident #3. The RNS failed to perform CPR on resident #3 and failed to instruct other staff members to do so. 15. Clearwater failed to provide adequate and appropriate health care and protective and support services to resident #3. 16. Clearwater failed to develop or implement policies or procedures to prevent resident #3 from being mistreated or neglected including, but not limited to, the following: (a) policies and procedures on advance directives; (b) policies and procedures on death of residents in the facility; (c) policies and procedures on nursing services; oY (a) policies and procedures on resident rights. 17. Based on all of the foregoing, Clearwater has violated: (a) Rule 59A-4.1288, Florida Administrative Code, which incorporates by reference Title 42 C.F.R. § 483.13(c), by failing to develop or implement written policies or procedures that prohibit the mistreatment or neglect of residents; and (b) Section 400.022(1) (1), Florida Statutes, by failing to ensure that each resident has a right to receive adequate and appropriate health care and protective and support services. 18. The foregoing is a class I deficiency because it has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care ina facility. § 400.23(8) (a), Fla. Stat. (2001). 19. The foregoing is an “isolated” deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or in a very limited number of locations. § 400.23, Fla. Stat. (2001). 20. Pursuant to Section 400.23(8) (a), Florida Statutes (2001) the Agency may assess a $10,000.00 fine against Clearwater for an isolated class I deficiency. 21. Pursuant to Section 400.19(3), Florida Statutes, Clearwater is subject to a 6-month survey cycle because it has been cited for a class I deficiency. Therefore, in addition to any other fees or fines imposed by the Agency against Clearwater under Chapter 400, Part II, Florida Statutes, the Agency shall impose a fine against Clearwater in the amount of $6,000.00 pursuant to Section 400.19(3). COUNT II CLEARWATER FAILED TO DEVELOP OR IMPLEMENT POLICIES OR PROCEDURES ON ADVANCE DIRECTIVES. 42 C.F.R. § 483.10(8); Rule 59A-4.1288, Fla. Admin. Code (2001) Rule 59A-4.106(4) (b), Fla. Admin. Code (2001) CLASS I DEFICIENCY WIDESPREAD 22. The Agency realleges and incorporates by reference paragraphs one (1) through seven (7) above as if fully set forth herein. 23. On or about June 29, 2002 the Agency conducted a survey at Clearwater. The Agency cited Clearwater for a widespread class I deficiency based on the findings below. 24. On or about June 29, 2002 an Agency surveyor toured the facility with the Administrator. The surveyor observed either a green dot or a red dot on the nameplates of resident rooms. During the tour, the Administrator stated that the colored dots alerted the staff as to whether or not a resident had a do-not- resuscitate (“DNR”) order or if full resuscitation was to be implemented. The Administrator also stated that the "dot" system had been implemented on or about June 15, 2002. The Administrator was unable to demonstrate to the surveyor how staff members would identify the resuscitation status of a resident if the resident was not in hig or her room. 25. On or about June 29, 2002 an Agency surveyor interviewed the registered nurse supervisor (*RNS”). During the interview, the RNS stated that on March 30, 2002 the only way to determine if a resident was to receive cardiopulmonary resuscitation (“CPR”), was to check the resident's clinical record. The RNS further stated that she had received no orientation regarding Clearwater's policies or procedures on CPR or other emergency medical procedures. 26. On or about June 29, 2002 an Agency surveyor interviewed a certified nursing assistant (“CNA #17). During the interview, CNA #1 stated that he recently attended one in-service on CPR and DNR orders. The in-service covered the red and green dot system only. CNA #1 further stated that he never received any training at Clearwater on a CNA'S role in a medical emergency. CNA #1 stated that on March 30, 2002 the nurse caring for resident #3 had to go to the nurse’s station to review resident #3’s clinical record in order to determine if the resident had an advance directive. 27. On or about June 29, 2002 an Agency surveyor interviewed CNA #2. During the interview, CNA #2 stated that he attended a recent in-service about "stickers." The CNA did not recall ever attending an in-service for "code (resuscitation) protocol." CNA #2 further stated that on or about March 30, 2002 a CNA had no way to determine if a resident had an advance directive because a CNA did not have access to a resident's clinical record. CNA #2 stated that, during that time period, the clinical record contained the resident’s resuscitation status. 28. On or about June 30, 2002 an Agency surveyor observed residents in Clearwater. Several residents did not have identification armbands on their person or the armband was attached to a piece of the resident's equipment (e.g., a wheelchair) not to the resident. 29. On or about June 29, 2002 an Agency surveyor interviewed the Administrator. The Administrator stated that all residents should have an armband, or that the armband should be affixed to a piece of the resident's equipment. During the interview, the Administrator could not explain how a resident’s status could be identified if the armband was not worn and the resident was separated from his/her equipment. 30. Clearwater failed to develop or implement policies or procedures on advance directives, which ensured the prompt identification of residents who had advance directives. 31. Clearwater failed to educate or adequately educate its staff on advance directive policies or procedures. 32. Based on all of the foregoing, Clearwater has violated: (a) Rule 59A-4.1288, Florida Administrative Code, which incorporates by reference Title 42 C.F.R. § 483.10(8), by failing to comply with the requirements specified in subpart I of part 489 of Chapter IV of Title 42 relating to policies or procedures on advance directives; and (b) Rule 59A-4.106 (4) (b), Florida Administrative Code, by failing to maintain policies or procedures on advance directives. 33. The foregoing is a class I deficiency because it has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. § 400.23(8) (a), Fla. Stat. (2001). 34, The foregoing is a “widespread” deficiency because the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. § 400.23(8), Fla. Stat. (2001). 35. Pursuant to Section 400.23(8) (a), Florida Statutes (2001) the Agency may assess a $15,000.00 fine against Clearwater for a widespread class I deficiency. 36. Pursuant to Section 400.19(3), Florida Statutes, Clearwater is subject to a 6-month survey cycle because it has been cited for a class I deficiency. Therefore, in addition to any other fees or fines imposed by the Agency against Clearwater under Chapter 400, Part ITI, Florida Statutes, the Agency shall impose a fine against Clearwater in the amount of $6,000.00 pursuant to Section 400.19(3). COUNT IIT THE SERVICES PROVIDED OR ARRANGED FOR BY CLEARWATER FAILED TO MEET PROFESSIONAL STANDARDS. 42 C.F.R. § 483.20(k) (3) (3) Rule 59A-4.1288, Fla. Admin. Code (2001) CLASS I DEFICIENCY WIDESPREAD 37. The Agency realleges and incorporates by reference paragraphs one (1) through seven (7) above as if fully set forth herein. 38. On or about March 27, 2002 resident #3 was admitted to Clearwater for antibiotic therapy, secondary to urinary tract infection complicated by methicillin resistant staphylococcus aureus. Resident #3 was expected to return home after completion of the antibiotic therapy. 39. On or about June 29, 2002 an Agency surveyor reviewed resident #3’s medical record. The record review revealed that resident #3 was alert, oriented, ambulatory, continent, cooperative and talkative upon admission. The clinical record did not contain an advance directive in which the patient consents to the withholding or withdrawing of cardiopulmonary resuscitation (“CPR”). 40. On or about June 29, 2002 an Agency surveyor interviewed a certified nursing assistant (“CNA #1”) who worked the 3:00 p.m. to 11:00 p.m. shift on or about March 30, 2002. on or about March 30, 2002 at approximately 4:15 p.m. CNA #1 found resident #3 in his room without a pulse and not breathing. CNA #1 said he immediately summoned the registered nurse supervisor (“RNS”). CNA #1 stated that the RNS began "running around and around" and did not appear organized. The licensed practical nurse (“LPN”) assigned to resident #3 was at the opposite end of the wing administering medication. According to CNA #1, this LPN came into resident #3's room to offer assistance. The LPN went to the nurse’s station to check resident #3's clinical record for an advance directive. CNA #1 said the LPN returned to resident #3's room and informed the RNS that resident #3 was to be fully resuscitated because the medical record contained no advance directive. The LPN advised the RNS to start CPR. According to CNA #1, the RNS told the LPN to return to administering medication and said "I've got it all covered". The RNS would not allow the LPN to offer further assistance. CNA #1 said the RNS then left resident #3’s room and did not return for approximately fifteen (15) to twenty (20) minutes. CNA #1 stated that the RNS did not perform CPR on regident #3 and did not instruct any other staff member to do so. 41. On or about June 29, 2002 an Agency surveyor interviewed CNA #2. CNA #2 worked the 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts on or about March 30, 2002 and was assigned to resident #3. CNA #2 said he took resident #3's blood pressure, temperature, pulse and respirations at approximately 2:30 p.m. to 2:45 p.m. on or about March 30, 2002. CNA #2 said he returned to resident #3's room at approximately 3:00 p.m. to adjust the nasal cannula delivering oxygen to the resident, which had slipped out of place. CNA #2 said resident #3 had been "fine" all day as the resident had been walking in his room and visiting with his wife earlier that day. CNA #2 said he was making his rounds after 4:00 p.m. and observed activity in resident #3's room so he went to see what was happening. Upon entering resident #3's room, CNA #2 found the RNS and another CNA present in the room. The RNS stated, "I have everything under control", and "You do not need to do anything". CNA #2 said the RNS then left resident #3’s room for about fifteen (15) to twenty (20) minutes. CNA #2 said he was curious as to why the RNS left the resident’s room. CNA #2 said neither the RNS nor any other Clearwater staff administered CPR to resident #3. 42. On or about June 29, 2002 an Agency surveyor interviewed the LPN assigned to resident #3 during the 3:00 p.m. to 11:00 p.m. shift on or about March 30, 2002. During the interview, the LPN said she had to check the resident’s medical record for the resident's code status. The LPN said the RNS "took over". The LPN further stated, "I guess she [the RNS] knew what to do". The LPN said she did not return to resident #3's room after the RNS instructed her to continue administering medication to the residents. 43. On or about June 29, 2002 an Agency surveyor interviewed the RNS who worked the 3:00 p.m. to 11:00 p.m. shift on or about March 30, 2002. During the interview, the RNS acknowledged that, upon finding resident #3 unresponsive and upon determining the resident’s full resuscitation status, CPR should have been performed on resident #3. The RNS said she did not initiate CPR or instruct any other staff member to do so. 44. On or about June 29, 2002 an Agency surveyor reviewed Clearwater’s CPR policy or procedure. Clearwater’s policy or procedure for CPR states: "unless a decision not to initiate CPR has previously been made by the resident/patient, CPR will be initiated for any resident/patient, visitor or staff member who experiences a cardiopulmonary arrest while in the facility." 45. Based on all of the foregoing, Clearwater has violated Rule 59A-4.1288, Florida Administrative Code, which incorporates by reference Title 42 C.F.R. § 483.20(k) (3) (i), by failing to ensure that services provided or arranged for by the facility met profession standards of quality. 46. The foregoing is a class I deficiency because it has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. § 400.23(8) (a), Fla. Stat. (2001). 47. The foregoing is a “widespread” deficiency because the problems causing the deficiency are pervasive in the facility or represent systemic failure that has affected or has the potential to affect a large portion of the facility's residents. § 400.23(8), Fla. Stat. (2001). 48. Pursuant to Section 400.23(8) (a), Florida Statutes (2001) the Agency may assess a $15,000.00 fine against Clearwater for a widespread class I deficiency. 49. Pursuant to Section 400.19(3), Florida Statutes, Clearwater is subject to a 6-month survey cycle because it has been cited for this class I deficiency. Therefore, in addition to any other fees or fines imposed by the Agency against Clearwater under Chapter 400, Part II, Florida Statutes, the Agency shall impose a fine against Clearwater in the amount of $6,000.00 pursuant to Section 400.19(3). COUNT IV CLEARWATER FAILED TO ENSURE THAT RESIDENTS WERE FREE OF ANY SIGNIFICANT MEDICATION ERRORS. 42 C.F.R. § 483.25(m) (2) Rule 59A-4.1288, Fla. Admin. Code (2001) Rule 59A-4.112(1), Fla. Admin. Code (2001) § 400.022(1) (1), Fla. Stat. (2001) CLASS I DEFICIENCY PATTERN 50. The Agency realleges and incorporates by reference paragraphs one (1) through seven (7) above as if fully set forth herein. 51. On or about January 28, 2002 the Agency conducted a survey at Clearwater. The Agency cited Clearwater for a pattern class I deficiency based on the findings below. 52. On or about January 28, 2002 an Agency surveyor reviewed resident #1’s medical record. The record review revealed that the resident was admitted to the facility on or 15 about June 15, 2000 with multiple diagnoses including, among others, dementia, hypertension, anemia, and chronic pain syndrome. 53. On or about January 28, 2002 an Agency surveyor reviewed resident #1's November 2001 Medication Administration Record. The record review revealed that Coumadin 8.5 milligrams was started on November 8, 2001 and discontinued on November 26, 2001. 54. On or about January 28, 2002 an Agency surveyor interviewed Clearwater’s staff. The interviews revealed that resident #1 had received Coumadin every day for eighteen (18) days. 55. On or about January 28, 2002 an Agency surveyor reviewed resident #1’s medical record. The record did not contain a physician's order for Coumadin. The record did contain an order dated November 26, 2001 discontinuing the Coumadin. The physician’s assistant documented “should not be on” on the order. There was no documentation in resident #1's medical record to support the use of an anticoagulant such as Coumadin. 56. Upon further review of resident #1’s medical record, the Agency surveyor discovered that Clearwater failed to perform coagulation laboratory testing to monitor the effect of the drug and to ensure safe anticoagulation therapy. 57. On or about January 28, 2002 an Agency surveyor reviewed resident #1’s laboratory records. The records showed 16 that, on or about November 21, 2001 a routine blood count was performed. The hemoglobin was 13.6 (normal range is 12-16 g/dl) and the hematocrit was 43 (normal range is 38-47%). On or about November 28, 2001, two (2) days after the drug cessation, the hemoglobin was 9.8 and the hematocrit was 31, way outside normal levels. By November 20, 2001 resident #1’s hemoglobin severely dropped to 5.3 and the hematocrit fell to 17. Another hemoglobin and hematocrit test was done on or about December 3, 2001. The hemoglobin was 5.3 and the hematocrit was 17. 58. A further review of the laboratory records by the Agency surveyor showed that a prothrombin time and an international normalized ratio were performed on or about November 30, 2001. Resident #1’s prothrombin results were markedly elevated at 73 seconds (normal range is 8.9-15.7). Resident #1’s international normalized ratio was 28.7 (normal range is 0.3-2.7). 59. Resident #1 expired on or about December 6, 2001. 60. Resident #1 was not free of any significant medication errors because Clearwater gave resident #1 the wrong medication for eighteen (18) days. 61. Clearwater failed to provide adequate and appropriate health care and protective and support services to resident #1. 62. Based on all of the foregoing, Clearwater has violated: (a) Rule 59A-4.1288, Florida Administrative Code, which incorporates by reference Title 42 C.F.R. $ 483.25(m) (2), by failing to ensure that residents are free of any significant medication errors; (b) Rule 59A-4.112(1), Florida Administrative Code, by failing to adopt procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident; and (c) Section 400.022(1) (1), Florida Statutes, by failing to ensure that each resident has a right to receive adequate and appropriate health care and protective and support services. 63. The foregoing is a class I deficiency because it has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. § 400.23(8) (a), Fla. Stat. (2001). 64. The foregoing is a “patterned” deficiency because more than a very limited number of residents are affected, or more than a very limited number of staff are involved, or the situation has occurred in several locations, or the same resident or residents have been affected by repeated occurrences of the same deficient practice but the effect of the deficient practice is not found to be pervasive throughout the facility. § 400.23(8), Fla. Stat. (2001). 65. Pursuant to Section 400.23(8) (a), Florida Statutes (2001) the Agency may assess a $12,500.00 fine against Clearwater for a pattern class I deficiency. 66. Pursuant to Section 400.19(3), Florida Statutes, Clearwater is subject to a 6-month survey cycle because it has been cited for this class I deficiency. Therefore, in addition to any other fees or fines imposed by the Agency against Clearwater under Chapter 400, Part II, Florida Statutes, the Agency shall impose a fine against Clearwater in the amount of $6,000.00 pursuant to Section 400.19(3). COUNT V CLEARWATER FAILED TO INVESTIGATION A SIGNIFICANT MEDICATION ERROR OR FAILED TO FILE A ONE DAY ADVERSE INCIDENT REPORT WITH THE AGENCY. § 400.147(7), Fla. Stat. (2001) CLASS I DEFICIENCY ISOLATED 67. The Agency realleges and incorporates by reference paragraphs one (1) through seven (7) above as if fully set forth herein. 68. On or about January 28, 2002 an Agency surveyor conducted a survey at Clearwater. The Agency cited Clearwater for an isolated class I deficiency based on the findings below. 69. On or about January 28, 2002 an Agency surveyor reviewed Clearwater’s records and interviewed staff. The foregoing revealed that Clearwater failed to initiate an investigation of an adverse incident in its facility. 70. On or about January 28, 2002 an Agency surveyor reviewed Clearwater’s records and interviewed staff. The foregoing revealed that Clearwater failed to notify the Agency of the adverse incident by filing with the Agency a one (1) day adverse incident report. 71. Based on the foregoing, Clearwater violated Section 400.147(7), Florida Statutes, by: (a) failing to initiate an investigation of an adverse incident; or (b) failing to notify the Agency of the adverse incident by filing a one (1) day adverse incident report with the Agency. 72. The foregoing is a class I deficiency because it has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. § 400.23(8) (a), Fla. Stat. (2001). 73. The foregoing is an “isolated” deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or in a very limited number of locations. $ 400.23(8) (a), Fla. Stat. (2001). 74. Pursuant to Section 400.23(8) (a), Florida Statutes (2001) the Agency may assess a $10,000.00 fine against Clearwater for an isolated class I deficiency. 75. Pursuant to Section 400.19(3), Florida Statutes, Clearwater is subject to a 6-month survey cycle because it has been cited for a class I deficiency. Therefore, in addition to any other fees or fines imposed by the Agency against Clearwater under Chapter 400, Part II, Florida Statutes, the Agency shall 20 impose a fine against Clearwater in the amount of $6,000.00 pursuant to Section 400.19(3). CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1) Make factual and legal findings in favor of the Agency on Counts I through V; 2) Impose a fine in the amount of $62,500.00 against Clearwater; 3) Assess a $6,000.00 survey fee against Clearwater pursuant to Section 400.19(3), Florida Statutes (2001) ; 4) Revoke Clearwater’s skilled nursing facility license (license number SNF1091096) pursuant to Section 400.121(3) (dad), Florida Statutes, (2001); 5) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001); 6) Uphold the Agency’s imposition of the Order of Immediate Moratorium; and 7) Grant any other legal and equitable relief as deemed necessary in the furtherance of justice. 21 Clearwater hereby is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights form and explained in the attached Explanation of Rights form. All requests for hearing shall be made to the Agency, and delivered to Lori C. Desnick, Assistant General Counsel, Agency for Health Care Administration, Building 3, Mail Stop #3, 2727 Mahan Drive, Tallahassee, Florida, 32308. CLEARWATER 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 THE AGENCY. Respectfully submitted on this 12°? day of September 2002. dur C. Qeorreke Lori C. Desnick Assistant General Counsel Florida Bar No. 129542 Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 Telephone: (850) 922-8854 Fax: (850) 921-0158 22 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original administrative complaint has been furnished via U.S. Certified Mail, Return Receipt Requested (# Woy 4659S (2H. W050 B22 | ) to Sal White, Administrator, Age Institute of Florida, Inc. d/b/a Clearwater Center, 1270 Turner Street, Clearwater, Florida 33756, and a true and correct copy of the administrative complaint sent via U.S. Certified Mail, Return Receipt Request, (# W/O AST (294 20650 3.348) to Bart Wyatt, Registered Agent, Age Institute of Florida, Inc. d/b/a Clearwater Center, 100 Second Avenue South, Suite 901, Saint Petersburg, Florida 33701, on this 12th day of September, 2002. Lori C. Desnick, Esquire 23 Exhibit A Order of Immediate Moratorium 02° STATE OF FLORIDA é Op AGENCY FO {HEALTH CARE ADMINIS’ TRATION STATE OF FLORIDA, AGENCY cre iv) VM y FOR HEALTH CARE ADMINISTRATION, Os a Petitioner, : AHCANO.: 2002041531 vs. ; AGE INSTITUTE OF FLORIDA, INC., d/b/z. CLEARWATER CENTER, Respondent. ORDER OF IMMEDIATE MORATORIUM THIS CAUSE having. com: before the Secretary of the Agency for Health Care Administration (hereinafter “Agency”) and afer careful review of the record and after being otherwise fully advised, the Secretary finds ar.d concludes as follows: FINDINGS OF FACT. 1. The Agency i: the tate agency charged with the responsibility of regulating and licensing nursing home facilities pursuant to Chapter 400, Part I], Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 2. Respondent, sige Ir stitute of Florida, Inc. d/b/a Clearwater Center (hereinafter “Respondent”), is licensed by the .\gency to cperate a 120-bed nursing home facility located at 1270 Turner Street, Clearwater, Fl. 33756, havin, been issued license number SNF1091096. As of July 2, 2002 the census at Respondent’s facility is eighty-seven (87). 3. The Agency Las de ermined that conditions at Respondent’s facility present 4 threat to the health, safety or welfere of Respondent’s residents and that such conditions are EXHIBIT i | ZO‘d cvist coo~ 2 Ir OvE9-28R -058:XC4 SAFILYYNOCYSH/0H 8 OW grounds for the imposition of an inumediate moratorium on admissions to Respondent's facility pursuant to Section 400.121(5)(a), Florida Statutes. | 4. The Agency affirm: that a condition in the facility that presents a threat to the health, safety or welfare of its residents is grounds for an iramediate moratorium on admissions to the Respondent, pursuant 10 40€.121 (5)(a), Florida Statutes. The documented violations and deficiencies, confirmed durir g a complaint su-vey at Respondent’s facility cn June 28, 2002 through June 29, 2002, and a subsequent mon toring visit on June 30, 2002, which put residents in immediate danger of death or serious harm, iaclude, but are not limited to, the following: A. Based on obse rvatic ms, interviews. and record review the facility did not employ a system for implementation which ensured promp: identification of residents who had formulated advance directives. There was no “acility-wide svstem in place to readily identify residents with advance directives and staff were rot knowle¢geable of when an advance directive was applicable. Lack of staff knewledye regarding advance directives and lack of a facility-wide system to promptly identify the wishes of residents and failure of staff to properly implement the facility policy for cardiopulmonary resuscitation (CPR) placed residents at risk for not receiving emergency lifesaving treatment and resulted in findings of Immediate Jeopardy. For instance, during tie ini-sial tour of the facility om 6/28/02 at 1:15 pain. with the administrator, it was observe 1 that there were e:ther green or red dots on the: nameplates of resident rooms. The administrator stated that these colored dots alerted the staff as to whether or not a resident had a do not resuscitate (DNR) order or if full resuscitation (code) was to be implemented. The adrninistr itor a so stated that this "dot" system had just been implemented on 6/15/02, subsequent to an investigition by ancther state agency. The administrator was unable to £0'd evist coo? 2 [ec 0vZ9-28P-0S8:X®4 — SAALANOGYIH/OH 8 IH demonstrate how staff members would identiiy the resuscitation status of a resident if that resident was not in the room wher: the red or green dot was available to view. Additionally, intervie w wi h the Registered Nurse (RN) Supervisor on 6/29/02, at 10:20 a.m., revealed that on March 30, 2902 the only way to determine ifa residenit was to receive cardiopulmonary resuscitaticn (CPR) after a cardio-pulmonary arrest, was to check the resident's clinical record. The RN Superviscr stated that she had received no orientation regarding the facility's practices and standards for CPR or emergency medical procedures. During an interview on 6/29/02, at 3:20 p.m., a certified nursing assistant (CNA) stated the only in-service that had teen given regardirg CPR or DNR status was just done and it only covered what the red and green dots designated. The CNA further stated that there was never an orientation as to a CNA's rol: in a medical errergency. The CNA further stated that on March 30, 2002 the nurse caring for Resilent #3 had to go to the nurses' station to review the clinical record for DNR status, which she assed on to the RN Supervisor by informing her that this i resident was to be fully resuscitated. Interview on 6/29/02, at 2:55 p.m., with the CNA revealed that there was a recent in- service about "stickers." The CN¢, did not recall ever attending an in-service for "code (resuscitation) protocol." This CNA further staved that on the date of March,30, 2002 a CNA would have had no way of determining if a resident was a DNR or not, becaiise a CNA did not have access to a resident's clinical record and at that time going into the record was the only way to determine resuscitation status. | In multiple observations during the mcnitoring visit conducted 6/30/02, it was noted several residents did not have iden ‘ification armbands on or that the armband was attached to a piece of the resident's equipment (j.e.: wheelchair) instead. An interview with the administrator vo'd ee:st coog 2 OIC OWZ9-28-0S8:X84 — SYILAUNOGUSH/0H 8 OW on 6/30/02, at 2:51 p.m., revealed ill residents should be wearing an armband, or that it should be affixed to a piece of their :quip nent. The administrator could not explain how a resident would be identified if the armband was not worn and the resident was separated from his/her equipment. | Interview with the RN Sup srvisor on €/30/02, at 2:36 p.m., revealed that approximately fifty percent of the residents are a iull code. RB. Based on record reviews and sta:¥ interviews the facility did not meet the needs of the residents by not providing: pror xpt assistance to one of one resident (#3), ‘who required immediate resuscitative inter venticns by staff who are certified in cardiopulmonary resuscitation (CPR), which resulted in finc ings of Immedia‘e Jeopardy. | The findings revealed that |tesident #3 was admitted to the facility on 3/27/02 for antibiotic therapy related to a urinary tract infection (UTI) complicated by methicillin resistant staphylococcus aureus. This resident had mul-ipl: diagnoses, but was expected to return home after completion of the antibi>tics. The medical record described this resident as alert and oriented, ambulatory, continent and talkative. There were no advanced directives in the resident's medical record and the resident was dzemed to be a full code for resuscitation purposes. The surveyor’s findin xs fur‘her revealed on March 310, 2002, between 4:00 p.m. and 4:30 p.m., the certified nursing assistant (CNA) noticed Resident # 3 in the same position for over an hour. The resident could not be roused and a pulse could not be detected. The resident was not yet cool to touch and there was only slight bluz discoloration at the upper lipiand the inside comers of the eyelids. 30 “d Svi8t goog 2 ONE OVC9-28-0S8:xe4 = SaxaLANOCYSH/OH 8 OW The CNA notified the RN Supervisor whe appeared “unorganized.” ‘A Licensed Practical Nurse (LPN) entered the rooin and then left to chack the clinical record to determine the resident’s resuscitation (code) status. The LPN retuned and informed the RN Supervisor that | the resident was full code (needed full resuscitation) and to start CPR. The RN Supervisor advised the LPN that she “had it (he situation) covered.” The RN Supervisor instructed the CNA and the LPN not to touch the resident and the RN Supervisor left the room for 15-20 minutes. The RN Supervisor retur 1ed to the roon) and instructed the LPN to call emergency rescue (911). The RN Super ‘isor acknowledged that CPR should have been started after the resident’s resuscitation status had been determined. She admitted that she did not initiate CPR on this resident, nor did she iistruct other staf? members to do so. C. Based on inte1 view:: and recorc, review, the facility failed to meet professional standards of quality on March: 30, ‘2002, by not following facility policy and procedure for implementing CPR in emergency situations for one of one resident reviewed (#3). The resident did not receive resuscitation. Mor: specifically, record review of the facility's standard for CPR states that "unless a decision not to initiate CPR has previously been made by the resident/patient, CPR will be initia:ed for any resi dent/patient, visitor or staff member who experiences a cardiopulmonary arr 2st while in te facility." The RN Supervisor acknowledged that upon finding an unresponsive -esident, afier determining full resuscitation status had been established, CPR should have beer started. The RN Supervisor stated she did not initiate CPR, nor did she instruct any other staff members ta de so. D. Based on observaticns, records reviews and interviews it was'determined the administration did not ensure care and services were implemented in a manner that enabled each resident to attain or maintain the highest pract cable physical, mental, and psychosocial well- 90"d vy:81 200? Z INC O¥CZ9-28¥ -0S8: xP 4 SAALNANOGUH/0H 3 OW being. The facility did not have a: acility-wide system in place to identify residents with advanced directives, staff wee not knowledgeable as to when an advanced directive was ; applicable, nor did they meet professional staridards of quality for one of one resident (#3), resulting in findings of Immediate Jeopardy. ! Specifically, an interview with the administrator and various staff members indicated there was no facility wide sy:tem ia place to identify which residents had advanced directives and which residents did not. On March 30, 2602 and up until June 15, 2002. the only way to identify which residents had .1 do rot resuscitete (DNR) orcler was to review the resident's clinical record. | An interview with the RN Supervisor on 6/29/02, at 10:20 a.m., revealed no training or in-services had been given on DNIi status, cardiopulmonary resuscitation (CPR), or facility protocol for managing medical em2rgencies. The RN delayed and omitted the initiation of CPR on a resident (#3), who had been dzemed a full code and who was found unresponsive on March 30, 2002. This resident subscquen ly expired. This practice was in violation of the facility's policy and procedure on the administration of CPR. | To further illustrate, ¢n interview with a CNA on 6/29/02, at 2:55 pan, who worked the 3:00 p.m. to 11:00 p.m. shift on March 30, 20:2 stated that at no time during employment at the facility was instruction given on DNR status, ‘CPR, or the CNA's role in a medical emergency. Record review of the aurse3 progress notes dated 3/30/02 for Resident #3 demonstrated the resident's condition was rot acvurately assessed or documented, specific to the events leading to the demise of this resident 20°d vr:st coo? ¢ lr ObZ9-287-0S8:X®4 — SHFLAWNOGUEH/OH 8 OW 5. The Agency kas jurisdiction over the Respondent pursuant to Chapter 400, Part I], Florida Statutes, and Chapter 59A.4, Florida A dmninistrative Code. 6. Based on th e “oregving Findin zs of Fact, the Secretary concliides that conditions in the facility present a threa’ to th health, safety or welfare of the residents and an immediate moratorium on admissions tc Res, ondent’s fecility pursuant to Section 400.121(5)(a), Florida Statutes, is fair, reasonable aid necessary to protect the public pursuant to Chapter 400, Part IT, ’ 1 Florida Statutes and Section 100.1 21(5)(a), Florida Statutes. 7. The Agency shall promptly proceed with any other administrative action to be brought against Respondent Iyased upon the fects set out herein and shall provide notice to Respondent of the right to a jearing under Section 120.57, Florida Statutes, at the time such action is taken. 1 ' IT JS THEREFORE, ORDERED THAT: 8. Respondent is hereb y UNDER AN IMMEDIATE MORATORIUM ON ADMISSIONS and shall not admi: any residents until the moratorium is lifted by the Agency. 9. Respondent shall post this notice of moratorium in a location visible to the public until the moratorium is lifted by the Agency. 10. Respondent shall provide the Agency a written plan of correction and notify the Agency when all violations are corrected so the Agency may inspect the Respondent's facility to determine if the moratorium nay te lifted. 2 ll. The Agency srall monitor the comditions at Respondent’s facility on a regular basis and notify the Respond nt wien the moratorium is lifted. 80°d vest coo~ 2 ie OvZ9-28-0G8: x4 SYSLENOTUSH/OH 3 OW DONE AND ORDERED in Tallahassve, Leon County, Florida, this o<2_day of July, St : CO Rhenda M. Sao MD, Secretary Axe ney for Health Care Administratfon 2002. NOTICE OF RIGHT TO JUDICIAL REVIEW : PURSUANT TO SECTION 120.68, 3LORIDA STATUTES, :THE AGENCY’S DETERMINATION THAT THE CONDITIONS AT RESPONDENT’S FACILITY PRESENT A THREAT TO THE HEALTH, 3AFETY CR. WELFARE OF RESPONDENT’S RESIDENTS SHALL BE JUDICIALLY FEVIEWABLE. REVIEW PROCEEDINGS ARE GOVERNED BY THE FLORIDA RULES (OF A?PELLATE PROCEDURE. SUCH PROCEEDINGS ARE ' COMMENCED BY FILING ONE: COPY OF .A PETITION FOR REVIEW IN ACCORDANCE WITH RULES 9.190(b\(2) AND 9.100%) AND (c) OF THE FLORIDA RULES OF APPELLATE PROCEDURE WITH THE AGENCY AND A SECOND COPY OF THE PETITION ACCOMPANIED BY A FILING FEE PRESCRIBED BY: LAW WITH THE DISTRICT COURT OF APPEZ.L WITHIN ‘THIRTY (30) DAYS OF THE DATE THIS ORDER OF IMMEDIATE MORATORIUM IS FILED. 60'd wy:8T coo7 2 NC OPC9-28P -0G8: Xe 4 Sua NENOUUH/OH 3 OW

Docket for Case No: 02-004041