vs. )
Respondent. )
Case Nos. 02-4416
Pursuant to notice, this cause came for formal proceeding on February 4 and 5, 2003, in St. Petersburg, Florida, before Fred L. Buckine, a designated Administrative Law Judge of the Division of Administrative Hearings (DOAH). The authority for conducting the hearing is set forth in Sections 120.569 and 120.57(1), Florida Statutes.
525 Mirror Lake Drive, North Sebring Building, Room 310J St. Petersburg, Florida 33701
For Respondent: Alfred W. Clark, Esquire
The issues for determination are: (1) whether the deficiency alleged as a result of a Complaint Survey conducted on June 18, 2002, is appropriately classified as a Class I deficiency; (2) whether a fine in the amount of $10,000 is appropriate; (3) whether the "Conditional" licensure status, issued October 29, 2002, is warranted; and (4) whether the alleged violation constitutes grounds for a six-month survey requirement and $6,000 survey fee.
The Agency for Health Care Administration (hereinafter AHCA), by separate Administrative Complaints (DOAH Case Nos. 02- 4416 and 02-4417) each dated October 28, 2002, and filed with DOAH on November 14, 2002, charged that Kindred Nursing Centers East, LLC, d/b/a Carrollwood Care Center (hereinafter Carrollwood) failed to ensure adequate supervision to prevent accidents for one resident who died from a bed side rail injury, which is a violation of Rule 59A-4.1288, Florida Administrative Code, incorporating by reference 42 C.F.R. (Code of Federal Regulations) Section 483.25(h)(2). AHCA further alleged that the actions or inactions of Carrollwood were a violation of the resident's rights, Section 400.022(1)(l), Florida Statutes (2001). AHCA's cited deficiency (Tag F324) presented a situation in which immediate corrective action was necessary
1 who was receiving care in the facility pursuant to Section 400.23(8)(a), Florida Statutes (2001). AHCA seeks to impose a Conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes (2001), effective June 18, 2002, as a result of a complaint investigation completed June 18, 2002, and impose a civil penalty in the amount of $10,000 and a survey fee in the amount of $6,000.
On November 14, 2002, Carrollwood filed a Petition for Formal Administrative Proceeding challenging those allegations, and the parties' joint motion for consolidation of the two cases dated November 20, 2002, was granted by Order dated November 25, 2002.
By stipulation, the parties agreed that AHCA bore the burden of proof in this proceeding to show that there was a basis in fact and law for the Class I assignment of the alleged deficiency; the assignment of the Conditional licensure, the intended fine, and the appropriateness or need of a six-month survey requirement with the cost borne by Carrollwood.
42 C.F.R. Sections 483.15 and 483.25; Sections 120.569 and 120.57(1), Florida Statutes; Chapter 400, Part II,
and Rules 59A-4.1288 and 28-106.216, Florida Administrative Code, was granted.
At the hearing, AHCA presented the testimony of three witnesses: Pamela Mraz, an employee, registered nurse and surveyor of nursing homes and other health care facilities; Marsha Lisk, an employee and registered nurse with extensive experience in Health Care Services Management, staff development and general hospital procedures, who was offered and accepted as an expert in nursing care; and Deputy Richard Lewis, Hillsborough County Sheriff's Office, the officer who took photographs of: (1) Resident 1 in bed, (2) his empty bed, and
(3) the room in which Resident 1 previously occupied. AHCA's Exhibits P-4 through P-13 were admitted into evidence. AHCA's Exhibits P-1 through P-3, photographs of Resident 1, his bed and a photograph of his room, were reviewed and given consideration by the undersigned. Due to confidentiality and privacy concerns, AHCA's Exhibits P-1 through P-3 were placed under seal and retained in the file.
Carrollwood presented the testimony of four witnesses: Rick Knight, facility administrator; Janet Schoeneckner, licensed practical nurse, the facility's charge nurse on the 7:00 a.m. to 3:00 p.m. shift on the day of Resident 1's death, whose duties included overseeing the certified nursing assistants, passing medications to residents and completing the
nurse's evaluation of residents; Marie Gianan, registered nurse and Minimum Data Set (MDS) coordinator, whose duties included directing nursing care of the residents, but not as a supervisor of the nurses providing care; and Carla Russo, registered nurse and the facility's director of nursing, whose duties included supervising the entire nursing staff and the certified nursing assistants and overseeing the residents' care for the facility.
The parties stipulated to the testimony Ann Nickerson would have given had she been available for the final hearing. Ann Nickerson, a certified nursing assistant, was on duty at Carrollwood on the day of Resident 1's death, but due to injuries resulting from an accident, she was not available to testify. The stipulated testimony was considered.
Carrollwood's Exhibits R-A through R-D were accepted into evidence.
The identity of the witnesses, exhibits, and any attendant evidentiary rulings are set forth in the two-volume Transcript of the hearing filed on February 25, 2003. Carrollwood's ore
30 days after filing of the transcript, due to two other final hearings scheduled with other Administrative Law Judges, was granted extending the time for Carrollwood to submit a proposed recommended order to March 3, 2003. By this motion, Carrollwood waived the requirement for this Recommended Order to be issued
within 30 days thereafter. See Rule 28-106.216, Florida Administrative Code.
The parties' Proposed Recommended Orders were timely filed on March 4, 2003, and have been considered.
At all times material hereto, AHCA was the state agency responsible for evaluating nursing homes in Florida pursuant to Section 400.23(7), Florida Statutes. As such, in the instant case it is required to conduct a complaint evaluation of nursing homes in Florida in accordance with Section 400.23(8), Florida Statutes (2000).
AHCA's evaluation of Florida nursing homes requires an assignment of a rating of standard or conditional to each licensee. In addition to its regulatory duties under Florida law, AHCA is the state "survey agency," which, on behalf of the federal government, monitors nursing homes that receive Medicaid or Medicare funds.
Carrollwood Care Center is a nursing home located at 15002 Hutchinson Road, Tampa, Florida, and is duly-licensed under Chapter 400, Part II, Florida Statutes.
On June 18, 2002, a complaint investigation survey was conducted at Carrollwood by Pamela Mraz, a surveyor for AHCA, who visited the Carrollwood facility to inquire into the death of Resident 1 that occurred on May 5, 2002. Ms. Mraz is a
registered nurse (RN) with over 20 years of nursing experience, including having served as a director of nursing and having completed more than 100 surveys of long-term care facilities.
She has been a surveyor for AHCA since September 2001.
During the course of her complaint survey of the facility, Ms. Mraz examined the facility's records pertaining to Resident 1's death. Her review indicated that the death of Resident 1 constituted failure to meet the standards set-up under Tag F324, as identified on the Form 2567-L of the U.S. Department of Health and Human Services' Health Care Financing Administration. The parties refer to this form as the HCFA 2567-L or the "2567."
The 2567 is the document used to charge nursing homes with deficiencies that violate applicable law. The 2567 identified each alleged deficiency by reference to a tag number. Each tag on the 2567 includes a narrative description of the allegations against Carrollwood and cites a provision of the relevant rule or rules in the Florida Administrative Code violated by the alleged deficiency. To protect the privacy of nursing home residents, the 2567 and this Recommended Order refer to the resident by a number (i.e., Resident 1) rather than by the name of the resident.
AHCA must assign a class rating of I, II or III to any deficiency that it identifies during a survey. The rating
reflects the severity of the identified deficiency, with Class I being the most severe and Class III being the least severe deficiency. There is one tag, Tag F324, at issue in the instant case, and, as a result of the complaint survey of June 18, 2002, AHCA assigned Tag F324 a Class I deficiency rating.
Tag F324, reflecting the requirement of 42 C.F.R. Chapter 483.25(h)(2), requires a facility to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. AHCA's witness, Ms. Mraz, was asked her opinion only regarding the facility's compliance with the requirements of Tag F324. She opined that Carrollwood did not provide adequate supervision and assistance devices to prevent the accidental death of Resident 1.
Resident 1's first admission to Carrollwood was on March 27, 2002. He was 89 years of age at the time of his admission, weighted 118 pounds and was 5'3" in height. He did not speak English. His initial screening assessment form reflected that he suffered with both short-term and long-term memory impairment, incontinency, decubitus ulcer, prostate cancer, malnutrition, heart problems, and was determined by Carrollwood's staff to be "bedfast" (in bed not less than
22 hours per day). Resident 1's range of motion was limited to his hands, arms and legs. Even though he could make occasional
slight changes in body or extremity positions, he was unable to make frequent or significant body changes independently.
Resident 1 was incapable of getting out of bed on his own, had no involuntary body movements, and required two persons to physically assist him in bed mobility. He could not use a wheel chair and experienced short periods of restlessness demonstrated by crying out in Spanish, his native language. Carrollwood's Fall Risk Assessment observation indicated that Resident 1 was virtually immobile and was, therefore, a minimum risk for falls. His assessment and care plan were adequate for his condition and comfort.
Resident 1 was placed in a semi-private room with his wife. A curtain between the beds separated them. Viewed from the foot of Resident 1's bed, his wife's bed would be to the left of his bed. On the right side of his bed, an upper half side rail was placed as an enabler.
On April 17, 2002, three weeks after his admission, Resident 1 was discharged to the hospital due to an increase in his temperature and congestion. On April 30, 2002, he returned from the hospital and was readmitted to Carrollwood. At this time, his second admission, he was assessed by Carrollwood's staff to be in a much weaker condition than at his initial admission, with additional diagnoses of sepsis, pneumonia, psychosis, anemia, depression and malnutrition.
Upon his second admission to Carrollwood, his assessment determination changed, and Resident 1 was classified as "bed-bound," as opposed to the prior assessment of bedfast, and he required extensive assistance, at least two persons to physically assist in transferring and dressing him with use of the upper bed side rail as enablers. The doctors' notes made in conjunction with the second admission did not include the use of upper side rails as in-bed enablers.
The Nurse Evaluation Assessment, dated May 1, 2002, reported that Resident 1 was completely dependent on staff for all his daily living activities, i.e., bathing, grooming, dressing, feeding, and toileting, because he could not do these functions for himself.
His Resident Care Plan reflected that he had a "potential for falls due to decreased cognition and physical mobility." His bed was lowered, the head of his bed was elevated, a second mattress was added, and a pneumatic call bell was attached. With knowledge of his updated medical history and further weakened condition, the nursing staff made an independent decision to use one upper bed side rail on Resident 1's bed.
The staff had received a Food and Drug Administration alert regarding potential dangers resulting from the use of side rails as recently as February 2002, and had participated in in-
service training sessions concerning the use of side rails. AHCA presented no evidence of authoritative directives for "the care giver's use of side rails" in long-term care facilities.
There was no evidence of statutory proscriptions, rules or accepted industry standards relating to the use of side rails in long-term care facilities. Therefore, each long-term care facility, including Carrollwood, may independently determine when, where, how and under what circumstances bed side rails will be used. Thus, AHCA's evidence of record affords no substantial basis to support its allegation that Carrollwood's decision to use an upper side rail on Resident 1's bed demonstrated a lack of adequate supervision that would cause or tend to cause immediate harm and/or death to Resident 1.
Marie Gianan, RN and MDS Coordinator for Carrollwood, which included coordination of assessments and care planning since July 2000, determined that Resident 1's April 17, 2002, transfer to the hospital was a "complete discharge" from Carrollwood. According to Ms. Gianan, Carrollwood's policy, as she understands it, is that once a resident is completely discharged, his or her medical records go to medical storage. Thus, Resident 1's return on April 30, 2002, was considered and treated as a new admission requiring an original initial assessment, a new care plan and 30 days thereafter, preparation of a new MDS. The procedure, as understood by Ms. Gianan, was
to not consider Resident 1's old medical records, old care plans, and old MDS, but rather to start anew based upon staff's observations, inquiries, and a check and review of current medical records and, thereafter, formulate an assessment and initial care plan within 24 hours of admission. The MDS would follow within 30 days after completion of the initial care plan.
Resident 1's April 2, 2002, care plan and fall risk assessment, indicated the following: skin problems that required repositioning him in bed every two hours; bath to be given on shower day or twice weekly; dehydration requiring liquids every night; placing his bed in a low position to prevent falls due to his decreased physical mobility; providing a pneumatic call bell; and using one upper side rail as an enabler placed on his bed. The care plan for Resident 1 met all requirements and does not indicate nor support an allegation of lack of supervision or inadequate care.
Ms. Gianan was adamant that Resident 1, although maybe weaker in body strength than before his discharge on May 8, 2002, was "mobile," per her interpretation of the word on his April 2, 2002, admission. She disagreed with the March 27, 2002, assessment of Resident 1 as being "immobile." Ms. Gianan has opined that, "immobile means you do not move in bed--you just stay in the position that you are put in--I do not agree with that evaluation."
Carrollwood's policy permits its MDS Coordinator to independently evaluate, assess, interview and otherwise determine the status and condition of each resident.
On May 5, 2002, the date of Resident 1's death, at approximately 6:45 a.m., Ann Nickerson, certified nursing assistant (CNA), entered Resident 1's room to empty his catheter. During this process, Resident 1 cried out in Spanish. His wife, awaken by the activity and Resident 1's cry, said to Ms. Nickerson "he is alright," and Ms. Nickerson completed her task and departed the room. An hour and one-half later, at approximately 8:15 a.m., Jermaine Martinez, CNA, entered Resident 1's room with his breakfast tray. Mr. Martinez found Resident 1 on the floor with his clothing pulled upward around his torso. His head was wedged between the bed's upper side rail and the mattress, with his chin resting upward against the upper side rail, thereby hyperextending his neck. Resident 1 had no pulse or respiration when found by Mr. Martinez. The Hillsborough County Medical Examiner, in an amended1 death certificate, listed Resident 1's cause of death as positional asphyxiation; the result of a lack of oxygen due to the position of his head wedged between the bed mattress and the upper side rail and hyperextension of his neck.
Within a few minutes of the discovery of Resident 1 on the floor by the Mr. Martinez, Resident 1's family entered the
facility for a visit and was stopped in the hall by the duty nurse who informed them of his death. During that brief period, and following the instructions given by the duty nurse,
Mr. Martinez and Ms. Nickerson moved the body of Resident 1 from the floor and placed him back in his bed, pulling the cover up to his chin. Thereafter, staff contacted Carla Russo, director of nursing, for further instructions.
Following instructions, staff called and released Resident 1's body to the funeral home without first notifying the Hillsborough County Medical Examiner. Because of this action, in violation of policy, no autopsy was performed on the body. It is undisputed that the facility's failure to immediately notify the Hillsborough County Medical Examiner of Resident 1's death constituted a violation of the facility's own policy and procedures regarding the death of residents at the facility. AHCA did not cite the facility for this particular facility policy violation. Therefore, there is no evidence to support an allegation of lack of supervision or inadequate care for this policy violation.
Based upon the care plan, nurse's notes, and medical records, it is undisputed that staff visited Resident 1's room an average of every two and one-half hours, if not more often, to provide medications and to attend the personal needs for both Resident 1 and his wife, during each 24-hour period from
April 2, 2002, to May 5, 2002. During those staff visits, while attending one occupant, staff would, could and did observe the other occupant. During those frequent room visits during the 24-hour period preceding Resident 1's demise, staff had not observed him to be restless or to independently move his body about in his bed. There is no evidence that Resident 1 was not under staff's observation, and, by implication, not under staff's supervision for any overly long period or an extended period of time of more than two and one-half hours during the April 2, 2002, through May 5, 2002, time period. The evidence does not indicate or support an allegation of lack of supervision or inadequate care by the facility.
From all medical records in evidence, it is clear that during his residency in the facility, Resident 1 never exhibited the type of behaviors that would indicate to staff he was a risk for falls; he had no recorded prior history of falls at home, at the hospital or at Carrollwood, he did not use a wheelchair and he could not independently ambulate. He was never observed by staff attempting to get out of bed, and his only infrequent and occasional expressions of restlessness were "crying out" in Spanish. The evidence of record does not indicate or support an allegation of lack of supervision or inadequate care by the facility.
AHCA presented no evidence of sufficient reliability to provide a plausible foundation upon which to conclude that the cause of Resident 1 moving from his bed-bound prone position to a sitting position on the floor with his neck wedged between the upper side rail and the bed mattress was due to a lack of supervision or inadequate care by the facility's staff. The evidence supports a plausible conclusion that Resident 1's demise, although inexplicable from the evidence of record, was nonetheless accidental.
CONCLUSIONS OF LAW
The Division of Administrative Hearings has jurisdiction over the parties and subject matter of this cause, pursuant to Sections 120.569 and 120.57(1), Florida Statutes.
Section 120.569(1), Florida Statutes, applies in all proceedings in which the substantial interests of a party are determined by an agency. Section 120.57(1), Florida Statutes, applies in those proceedings involving disputed issues of material fact. Carrollwood is a facility substantially affected by the conditional rating.
AHCA bears the burden of proof of alleged deficiencies and consequences for the deficiencies. Florida Department of Transportation v. J.W.C. Company, Inc., 396 So. 2d 778 (Fla. 1st DCA 1981); and Balino v. Department of Health and Rehabilitative Services, 348 So. 2d 349 (Fla. 1st DCA 1977). AHCA's burden of
proof relating to a conditional rating is by a preponderance of the evidence, failing a contrary instruction set forth in Chapter 400, Part II, Florida Statutes. Section 120.57(1)(j), Florida Statutes. The burden of proof is on AHCA. See Beverly Enterprises v. Agency For Health Care Administration, 745 So. 2d 1133 (Fla. 1st DCA 1999). The burden of proof to impose an administrative fine is by clear and convincing evidence.
Department of Banking and Finance v. Osborne Stern and Company, 670 So. 2d 932 (Fla. 1996).
A nursing home licensed in this state is given a quality rating on the basis of its substantial compliance with two independent bodies of law: state law and federal law. The quality rating of nursing homes is unique to the State of Florida. While federal law deficiencies, for purposes of sanctions, may fall under any of the regulations in 42 C.F.R. Part 483, Rule 59A-4.128, Florida Administrative Code, effective October 13, 1996, through May 5, 2002, for rating purposes, limits the consideration of federal deficiencies to those federal deficiencies constituting "substandard quality of care." "Substandard quality of care" refers only to a certain level of non-compliance with three particular sections of 42 C.F.R. Part 483: to wit, Sections 483.13, 483.15, and 483.25. Florida Administrative Code Rule 59A-4.128's use of "substandard quality of care" was added by the amendment to the rule of October 13,
1996, and was recognized in rule challenge proceedings as an appropriate reference to federal law in Florida Health Care
Association v. Agency for Health Care Administration, 18 F.A.L.R. 3458, 3471 (DOAH 7/16/96).
The state "Class I," "Class II," and "Class III" scheme of deficiencies is simply broader than the federal "substandard quality of care" scheme. There is no indication in Chapter 400, Part II, Florida Statutes, that the legislature intended for the statutory definitions to be limited by federal law. Thus, under Rule 59A-4.128(4), Florida Administrative Code, effective October 13, 1996, through May 5, 2002, a nursing home is rated as conditional if one of the state "class" deficiencies is found, or if one of the federal "substandard quality of care" deficiencies is found.
In summary, a separate inquiry into substantial compliance with (1) state law and (2) federal law is required to ascertain the proper quality rating of a nursing home.
"F" tags are Center for Medicare and Medicaid Services (CMS) (formally Health Care Financing Administration (HCFA)) data tags assigned to each of the Federal regulatory requirements for long-term care facilities and are found in
42 C.F.R., Chapter 483.
Interpretive guidelines are found in the State Operations Manual required of the states in conducting surveys
for Medicare and Medicaid certification. In conducting a survey, AHCA's surveyors rely on these guidelines in determining whether a facility is in compliance with 42 C.F.R., Chapter 483.
42 C.F.R., Section 483.15(b), in relevant part, states that: "Clear and convincing evidence" has been defined by Slomowitz v. Walker, 429 So. 2d 797, 799 (Fla. 4th DCA 1983), as "highly probable," "a firm belief," "no substantial doubt," and further states:
The evidence must be of such weight that it produces in the mind of the trier of fact a firm belief or conviction, without hesitancy, as to the truth of the allegations sought to be established.
Id. at 800.
Section 400.23(7), Florida Statutes (2001), provides in pertinent part:
(7) The agency shall, at least every
15 months, evaluate all nursing home facilities and make a determination as to the degree of compliance by each licensee with the established rules adopted under this part as a basis for assigning a rating to that facility. The agency shall base its evaluation on the most recent inspection report, taking into consideration findings from other official reports, surveys, interviews, investigations and inspections. The agency shall assign a licensure status of standard or conditional to each nursing home.
* * *
(b) A conditional rating means that a facility, due to the presence of one or more Class I or Class II deficiencies, or Class
III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part, with rules adopted by the agency. If the facility has no class I, class II, or class III deficiencies at the time of the followup survey, a standard licensure status may be assigned.
AHCA's Rule 59A-4.128, Florida Administrative Code, describes the same requirements as the statute cited above and adopts by reference the applicable federal regulations. With one exception, not relevant here, Rule 59A-4.128, Florida Administrative Code, was determined valid in Florida Health Care
Association, Inc., et al. v. Agency for Health Care Administration (DOAH Case Nos. 96-4367RP and 95-4372RP, Order entered July 16, 1996).
The federal regulations at Title 42 C.F.R. Part 483, Subsection B, provides in pertinent part:
Section 483.25 Quality of Care
Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care.
* * *
Accidents. The facility must ensure that--
The resident environment remains as free of accident hazards as is possible; and
Each resident receives adequate supervision and assistance devices to prevent accidents.
AHCA may issue a facility a Conditional license when, after a survey, a facility has one or more Class I or Class II deficiencies, or Class III deficiencies not corrected within the time established by AHCA. Section 400.23(8)(b), Florida Statutes (2001). AHCA also claims it may issue a Conditional license to a facility where a facility is not in substantial compliance with rules adopted under the Omnibus Reconciliation Act.
Section 400.23(8)(a), Florida Statutes, (2001), provides in pertinent part that:
A class I deficiency is a deficiency that the agency determines present a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency. . . .
In the case at bar, AHCA's Administrative Complaint contained one count alleging specifically that Carrollwood failed to ensure adequate supervision to prevent an accident to Resident 1 who died as a result of a bed side rail injury.
AHCA's Administrative Complaint does not allege that Carrollwood failed to provide "assistance devices," which is one of the requirements of 42 C.F.R. Section 483.25(h)(2). Thus, the only issue is whether Carrollwood provided adequate supervision.
Carrollwood argues convincingly in its Proposed Recommended Order that "[T]he simple existence of an accident or fall is not evidence, standing alone, of a nursing home's failure to provide adequate supervision. A nursing home is not strictly liable for accidents." Beverly Enterprises - Florida, Inc. d/b/a/ Beverly Health and Rehabilitation Center - Rio Pinar
v. AHCA, DOAH Case No. 97-2017, Final Order entered July 2, 1998. AHCA must show some direct and non-speculative link between "lack of or failure to ensure adequate supervision" and an "accident" or likelihood of an "accident."
In the this case, AHCA failed to identify any specific or combination of elements of Carrollwood's assessments, care plans, or care giving for Resident 1 which were inadequate. AHCA failed to provide evidence to prove that Carrollwood's staff's observations and/or assessments of Resident 1's physical and mental behavior or condition were inadequate or too infrequent to detect behavior which could arguably lead them to believe Resident 1 was in danger of a bed side rail injury.
Likewise, AHCA's contention that Carrollwood's noncompliance caused or which was likely to cause serious injury
or death, as the basis for the alleged violation constituting a "Class I" deficiency, is not supported by the evidence.
A Conditional license and monetary penalties are appropriate only if the alleged Class I deficiency existed. AHCA has failed to prove that a deficiency of any class existed. Accordingly, the Administrative Complaint should be dismissed.
Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order dismissing in its entirety the Administrative Complaints filed in this cause.
DONE AND ENTERED this 27th day of March, 2003, in Tallahassee, Leon County, Florida.
FRED L. BUCKINE
Filed with the Clerk of the Division of Administrative Hearings this 27th day of March, 2003.
1/ No autopsy was performed on Resident 1. The initial Certificate of Death prepared for Resident 1 states the cause of death was due to "cardio respiratory arrest" (heart attack) and that an underlying cause was "coronary artery disease." The "Affidavit of Amendment to Medical Certification of Death," prepared and filed by the Hillsborough County Medical Examiner, states the immediate cause of death was "positional asphyxia." The Amendment to Medical Certification of Death is considered by the undersigned as the factual cause of death.
Alfred W. Clark, Esquire
525 Mirror Lake Drive, North Sebring Building, Room 310J St. Petersburg, Florida 33701
Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3
Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive
15 days from the date of this Recommended Order. Any exceptions to this Recommended Order should be filed with the agency that will issue the Final Order in this case.
