~ ~ DpdMbd STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Certified Article Number AGENCY FOR HEALTH CARE ADMINISTRATION, 710b 4S75 L294 e049 B57 SENDERS RECORD Petitioner, vs. AHCA NO. 2002042241 THE CHRISTIAN AND MISSIONARY ALLIANCE FOUNDATION, INC., D/B/A SHELL POINT NURSING PAVILION, Respondent. / ADMINISTRATIVE COMPLAINT ‘ 5 AURA oa Oe. oe e com ey CARE ADMINISTRATION COMES NOW the AGENCY FOR HEALTH (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against THE CHRISTIAN AND MISSIONARY ALLIANCE FOUNDATION, INC d/b/a SHELL POINT NURSING PAVILION (“Respondent”), pursuant to Section 120.569, and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION impose an administrative fine 1. This iS an action to upon Respondent pursuant to Section 400.419, Florida Statutes. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. 3. AHCA has jurisdiction over Respondent pursuant to Chapter 400 Part III, Florida Statutes. 4. Venue vests pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 5. 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 the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code, respectively. 6. Respondent operates a 180-bed skilled nursing facility, located at 15000 Shell Point Blvd., Fort Myers, Florida 33908. Respondent is licensed by AHCA as a skilled nursing facility having been issued license number SNF1498095, certificate number 8768, with an effective date of June 6, 2002 and an.expiration date of Navember 30, 2002. 7. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. COUNT I RESPONDENT FAILED TO PROVIDE ADEQUATE AND APPROPRIATE HEALTH CARE AND PROTECTIVE SUPPORT AND SERVICES, IF AVAILABLE; PLANNED RECREATIONAL ACTIVITIES; AND THERAPEUTIC AND REHABILITATIVE SERVICES CONSISTENT WITH THE RESIDENT CARE PLAN, WITH ESTABLISHED AND RECOGNIZED PRACTICE STANDARDS WITHIN THE COMMUNITY, AND WITH RULES AS ADOPTED BY THE AGENCY. SECTION 400.022 FLA. STAT. (2001). tu 8. AHCA re-alleges and incorporates by reference paragraphs one (1) through seven (7) above as if fully set forth herein. 9. On or about June 3-6, 2002, AHCA conducted a survey at Respondent’s facility. A class II deficiency was cited against Respondent based on the findings below: Based on observations, record review and staff interviews, the facility failed to provide care and protective services for 2 of 3 sampled residents (#14 and #15) on the second floor dementia unit. This is evidenced by the continued resident-to-resident altercations without facility staff providing on-going interventions, implementation of facility abuse policy, or development of a therapeutic plan of care. The findings include: l. During the initial tour of the second Noor on 6/03/02 at approximately 9:30 AM, Resident #14 was identified by nursing staff as having "injured" another resident (#15) the night before (6/02/02). According to the nurses notes for Resident #15 on 6/02/02 at 1745 (5:45 PM) “ (resident's name) was knocked to the ground by another resident. She hit her head and tore open the L (left) forearm. Her L. knee has a quarter-sized abrasion - instantly swollen...... had a small abrasion L. side of head - ice applied." L. knee abrasion with obvious pain and swelling - ice applied to knee also. Lg (targey hematoma (bruise) from L. wnst to mid forearm with Ig deep skin tear. Skin re-approximated and steri-stripped - dressed with telfa and Kling per Dr.___.". The physician was called, examined the resident and noted the presence of a “contusion” of the L. parietal area (the head). Review of Resident #15's record showed a nurse's note dated 5/19/02 at 2100, "Hit in back of head by another resident for no apparent reason." Interview with nursing staff on 6/04/02 at approximately 11:00 AM revealed the resident had been struck by Resident #14 during this incident as well. However, no injuries were noted during this altercation. 2. Review of the facility Policy related to "Abuse, Neglect, or Misappropriation of Property” dated 12/12/00 reveated "5S. Should abuse be expected (suspected ?) to be resident-to-resident initiated, the residents will be separated, the environment will be reviewed as to the stimuli that may have tnggered a catastrophic response..... Corrections to the environment will be implemented, the residents will be evaluated for injury, the residents will be interviewed (where practicable).” 3. Review of the clinical record for Resident #14 showed documentation in the nurse's notes for 6/02/02 of escalating behavior throughout the day i.e. "She has had one confrontation after another today with residents - not staff." There is no documentation to indicate any interventions until resident #14 injured resident #15. Review of the plan of care (both current and past) showed no interventions for aggressive, assaultive behavior by this resident or environmental review for stimuli. Intervicw with the Social Worker on 6/04/02 at approximately 1:30 PM revealed no interventions had been planned or written by him for the aggressive behavior, although the psychiatric nurse had been called regarding reinstating the use of an antipsychotic medication. Interview with the R.N. in charge of the unit as well as the DON (Director of Nursing) revealed no changes in the plan of care had been implemented since the altercation. 4. Further review of the clinical record for Resident #14 disclosed at least 12 other incidents documented since March 9" of 2002 in which this resident struck, slapped or pushed other residents (3/09, 4/07, 4/18, 4/21, 4/30, 5/03, 5/04, 5/13, 5/18, 5/19, 5/24, and 5/25). The resident's record revealed her to have “expressive aphasia due to CVA (Cerebrovascular Accident)" and to be moderately impaired for cognition. The resident was observed pacing around the 2™ floor unit and in the dining room for lunch on 6/04/02. She was minimally able to communicate with gestures. Review of the "Behavior/Intervention monthly Flow Record " showed the behaviors being monitored as the following: "Mood changes, Delusions, Depressed, and Compulsive." Interview with the DON on 6/04/02 at approximately 3:30 PM verified these “behaviors” were inappropriate for this resident, unable to be observed, and emotions unable to be verbalized by the resident. 5. The clinical record and interviews with administrative nursing staff on 6/05/02 at approximately 3:30 PM revealed interventions at the time of an incident included 1:1 monitoring and removal to her room. Medication had been utilized but discontinued. There was no documented plan of care outlining interventions to prevent this resident from continuing to injure others or herself. 10. Based on all of the foregoing, Respondent violated Section 400.022 Florida Statutes (2001), by failing to provide adequate and appropriate care and protective services to the residents, consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. 12. 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 as practicable physical, mental, and psychosocial well-being, defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. AHCA is authorized ta impose a fine against Respondent in. the amount. of $2,500. CLAIM FOR RELIEF WHEREFORE, AHCA respect fully requests the following relief: a) Make factual and legal findings in favor of AHCA. b) Impose a fine in the amount of $2,500.00. ¢c) Any other general and equitable relief as deemed appropriate. Dated: August 29th, 2002 Agency for Health Care Administration Senior Attorney Fla. Bar. No. 0174629 2727 Mahan Drive, MS#3 Tallahassee, Florida 32308 (850) 921-6362 (office) NOTICE Respondent, The Christian and Missionary Alliance Foundation, Inc., d/b/a Shell Point Nursing Pavilion 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. THE CHRISTIAN AND MISSIONARY ALLIANCE FOUNDATION, INC., D/B/A SHELL POINT NURSING PAVILION 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 29th day of August 2002. Seas, 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 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 8576} to Shell Point Nursing Pavilion, 15000 Shell Point Blvd., Fort Myers, Florida 33908 on the 29th day of August, 2002. AGENCY FOR HEALTH CARE ADMINISTRATION JO Cc. Ata 2 -Fla. Bar. No. 0174629 2727 Mahan Drive, Ms#3 Tallahassee, Florida 32308 (850) 921-6362 (office) (850) 921-0158 (fax)

Docket for Case No: 02-004160

Orders for Case No: 02-004160