STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION | STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, OD -Y Ve CASE NO: 2002046570 vs. 2001073171 ALTERRA HEALTHCARE CORPORATION, d/b/a ALTERRA CLARE BRIDGE OF WEST MELBOURNE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Alterra Healthcare Corporation, d/b/a Alterra Clare Bridge of West Melbourne (hereinafter “Respondent”) and alleges the following NATURE OF THE ACTION 1. This is an action to impose administrative fines on Respondent pursuant to Sections 400.419(1) (b) and 400.419(9), Florida Statutes. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Section 120.569 and 120.57 Florida Statutes and Chapter 28-106 Florida Administrative Code. 3. AHCA, Agency for Health Care Administration, has jurisdiction over Respondent pursuant to Chapter 400 Part III, Florida Statutes. 4. Venue lies in Brevard County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28 Florida Administrative Code. PARTIES 5. Agency for Health Care Administration, State of Florida is the enforcing authority with regard to assisted living facility licensure law pursuant to Chapter 400, Part III, Florida Statutes and Rules 58A-5, Florida Administrative Code. 6. Respondent is an assisted living facility located at 7199 Greenboro Drive, Melbourne, FL 32904. Respondent, is and was at all times material hereto, a licensed facility under Chapter 400, Part III, Florida Statutes and Chapter 58A-5, Florida Administrative Code, having been issued license number 9766. COUNT I RESPONDENT FAILED TO PROVIDE CARE AND SERVICES APPROPRIATE TO THE NEED OF ALZHEIMER’S RESIDENTS RESULTING IN FRACTURES FOR TWO OF TEN SAMPLED RESIDENTS AND VIOLATING Fla. Admin. Code R. 58A-5.0182 CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. On or about October 15, 2001, a survey was conducted at the facility. AHCA cited Respondent based on the findings below, to wit: Based on interview and record review, the facility failed to provide care and services such as nursing assessments post fall, appropriate to the needs of Alzheimer's residents, which resulted in fractures for two of 10 sampled residents. Findings: 1. Resident record review revealed a DOEA form 1823 dated 9/5/0, form documents resident #8 with diagnosis of dementia, congestive heart failure, hypertension, diverticulitis, and degenerative joint disease, it also identifies resident as at risk for falls and short & long term memory loss. Resident record review revealed the following: 9/27/01 1300(1PM) "Resident assisted from sitting position on floor this AM, states her stomach hurts. Daughter was here and aware of complaint -medicated with Tylenol this AM, but continues to state stomach hurts. Will continue to monitor". 9/27/00 2100(9PM) "Nursing spoke with resident's daughter. Daughter requests call MD in AM to see resident. Resident continues to c/o abdominal pain and also leg pain, refuses to walk." 9/28/0111:05 AM "Nursing spoke with PA (physician's assistant) re: abdominal pain and left hip pain. Orders received for x-ray left hip, clear fluids today, Tylenol QID for two days. Call placed to daughter, left message on answer phone” 9/28/01 13:15(1:15pm) "nursing X-ray taken of left hip, awaiting results" 9/27/01-late entry- (that was entered following a noted dated 9/28/01) “Resident observed sitting on floor in her room this AM, assisted to feet and to chair c/o generalized pain". 9/28/01 4:45 “results of X-ray FX (fracture) Resident transported via ambulance to HRMC. Dr. and daughter notified." X-ray report dated 9/28/01 "fracture with shortening sub copate region of the femoral head", left hip. Record review revealed that no written notations are available to document that the facility provided basic nursing assessment, including range of motion, or neuro checks after resident was found sitting on the floor or after resident was complaining of left leg pain and refused to walk. Administrator and DON stated that they know resident well, was believable and resident stated she/he sat on floor due to stomach ache, therefore the facility believed the resident. Per staff interview, the facility did not consider this an incident due to fall but rather resident's choice to sit on floor, due to stomachache. Per staff interview and record review, time of incident is unknown . 2. Record review for resident #10 revealed resident with diagnosis Alzheimer and diabetes. Review of resident log for resident #10 revealed note dated 10/2/01 10:15 PM "Nurse found resident laying on floor on right side with skin tear to right elbow. Bloody drainage noted cleansed with water, applied Telfa and wrapped with Kerlix to keep him/her from scratching. Medicated with Atarax for itching, blood pressure 170/100 and heart rate 88." X-ray report dated 10/3/01 revealed "fracture neck of femur, age?" Based on record review there was no documented evidence the facility provided basic nursing assessment, including range of motion, or neuro checks for resident post fall. Per staff interview, the facility had not written an incident report because the incident was not considered a fall but rather resident was found lying on the floor. 9. The above actions or inactions are a violation of Rule 58A-5.0182, Florida Administrative Code, which requires that an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. 10. The above referenced violation constitutes the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (b), Florida Statutes, the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 11. Pursuant to Section 400.419(9), Florida Statutes, AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint or for monitoring visits conducted under 400.428 (3) (c) to verify the correction of the violations. COUNT II RESPONDENT FAILED TO PROVIDE SUPERVISION NECESSARY TO ENSURE HEALTH, SAFETY, AND WELL-BEING OF THREE RESIDENTS DIAGNOSED WITH ALZHEIMER'S DISEASE AND, AT RISK FOR WANDERING, RESULTING IN THE DEATH OF ONE RESIDENT IN VIOLATION OF Fla. Admin. Code R. 58A-5.0182(1) (b) (c) CLASS II DEFICIENCY 12. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 13. On or about July 15, 2002, a survey was conducted at the facility. AHCA cited Respondent based on the findings below, to wit: 1) The facility failed to provide the supervision necessary to ensure the health, safety, and well-being of 3 residents diagnosed with Alzheimer's disease and at risk for wandering, per record review and interviews. 2) Interview with the facility nurse on 7/15/02 revealed she came to work at 5:45 AM the morning of 7/13/02. She said the cook came to her at around 6:45 AM and told her she stepped out the kitchen door to have a cigarette and Saw a hat floating in the retention pond behind the facility. Both went to the pond and saw the hat floating and something blue under the water. They then went back inside and began a room to room search for the resident who owned the ball cap and to account for all residents. At 7:00 AM, 911 was called. When police arrived, they took them to the pond, and it was then confirmed that the resident had drowned in the pond. 3) Tour of the facility with the Administrator revealed the facility has a very elaborate alarm system on all exits. The front and back doors (by the kitchen) have key pads to allow staff to enter a pass number to exit without setting off the alarms. Each of the 4 wings have exit doors. None have a key pad. When the doors were opened, an alarm went off. There was a small interior hall (4' x 4') and then another door opening to the outside. When that door was opened another alarm sounded. The only way to stop the alarm was to re-set the alarm. There isa panel which lights up to indicate which door has been opened so that staff can quickly locate the open door and stop the resident from exiting through the second door. There is a panel on each court. It was also learned that due to fire code, the doors must all release if continuous pressure is applied to the push bars. The Alarm panel was checked by the police and found to be in perfect working order. 4) Interview with the Administrator revealed 3 resident care assistants were working the 11PM to 7 AM shift on 7/12-13/02. Review of personnel file for each of the 3 staff revealed staff hired 2/11/02, 6/11/02 and 7/12/02 had all been trained on facility policies and procedures concerning door alarms and visitors exiting the facility as outlined in policy issued 11/29/01. All 3 staff had signed copies of the policy in their personnel file. The policy states that "When a door alarm sounds all staff will respond to the appropriate location. No alarms are to be silenced as this does not engage the lock. You must reset the alarm to re-engage the lock. A staff member must be at the door until the lock is engaged. Once the lock is engaged test the door security by pushing the push bar. If it is secure, it will sound." Personnel file for staff hired 2/11/02 revealed she was found sleeping on her shift at 3:30 am on 7/12/02. Review of incident reports revealed on 5/11/02, 2 staff on the 11 PM - 7 aM shift, who are no longer employed by the ALF, were asleep with no supervisor. They had locked residents into their rooms so as not to be disturbed. One staff had brought an alarm clock into the ALF, which was heard to go off at 3:00 AM by the person who caught them sleeping. S) Record review for 4 residents identified as residents who try to elope revealed all 4 had gotten out of the ALF. Resident #1 was admitted 3/1/00. Health assessment dated 2/15/00 states the resident has a diagnosis of alzheimer's, dementia with depression, delusions, cognitively impaired, wanders, and requires fall precautions. Nursing notes 2/22/02, 3/16/02, 5/8/02 all state resident becomes agitated, kicking and hitting the staff when they attend to his/her personal care needs. Note 6/15/02 stated resident "agitated, hitting other residents and staff, was up all night, refused to go to bed, when staff put to bed, he/she hit them." Note 6/16/02 at 5 PM states "resident agitated, kicking and hitting, angry, Trying x 4 to elope." 6) Record review for resident #2 admitted 6/17/02 revealed the resident had a diagnosis of degenerative dementia, alzheimer type. Nursing notes dated 6/17/02 at 6:30 state "patient said to be at risk for elopement" Note 6/17/02 at 10:30 PM state "became agitated going from door to door. Patients then tried getting out of back door on D hall, got to resident just as he/she was leaving the building." Note 6/18 at 5:30 AM: "Looking for way out." Note 6/19/02: "Anxious trying to exit building" Note 6/20/02: "continues to be confused and looking for a way out." Note 6/24/02: "At 1645 resident missing from supper-last seen at 1640 ...all rooms in building searched...911 called...resident located at 1715 ambulating along sidewalk ...returned to residence." 7) Record review for resident #3 admitted 8/30/00 with a diagnosis of dementia. Nursing note 4/7/02 states "tries to elope at times." Note 2/16/02: "Elopes occasionally, mostly after going out with family, but returns when asked." Note 3/11/02: "Has to be closely monitored...always tries to elope" after family visit. 8) Incident report dated 3/18/02 revealed a 4th resident had gotten out of the building on 3/15/02 at 4 PM. "RD (resident director) informed by cook of resident's elopement after the fact. No injuries apparent." 14. The above actions or inactions are a violation of Section 58A-5.0182(1) (b) (c), Florida Administrative Code, which requires Respondent to offer personal supervision, as appropriate for each resident, including daily observation by designated staff of the activities of the resident while on the premises and awareness of the general health, safety, and physical and emotional well-being of the individual. 15. The above referenced violation constitutes the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (b), Florida Statutes, the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 16. Pursuant to Section 400.419(9), Florida Statutes, AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint or for monitoring visits conducted under 400.428 (3) (c) to verify the correction of the violations. COUNT IIT RESPONDENT FAILED TO COMPLY WITH THE RESIDENT’S RIGHT TO LIVE IN A SAFE ENVIRONMENT, FREE FROM ABUSE AND NEGLECT VIOLATING Section 400.428, Florida Statutes CLASS II DEFICIENCY 17. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 18. On or about July 15, 2002, a survey was conducted at the facility. AHCA cited Respondent based on the findings below, to wit: 1) The facility failed to comply with the resident’s right to live in a safe environment, free from neglect. 2) TV news report on 7/13/02 revealed an elderly resident with alzheimer's disease had drowned in a retention pond behind the assisted living facility where the resident lived. Tour of the facility with the Administrator on 7/15/02 revealed the facility has a very elaborate alarm system on all exits. An alarm sounds whenever a door opens. The administrator stated the alarm system was working the night and morning of 7/12 and 7/13/02 during the 11 PM to 7 AM shift. The administrator stated 3 staff worked that shift and all had been trained in procedures concerning the alarm system and resident safety. Personnel file review verified all had received the training by signed copies of the policy and procedure in their files. 3) Interview 7/22/02 with Detective , Criminal Investigations Division, West Melbourne Police Department, revealed that her many interviews with the 3 staff resulted in the following scenario: The resident was seen at 2 AM and given a banana and orange juice. He was again seen at approximately 5:15 AM within 10 feet of the front door. At 5:30 AM the alarm sounded that a door was open. One staff was changing a resident when the alarm sounded. The staff member finished and went to the front door because the panel indicated it was the front door which had been opened. She stated she did not shut off the alarm and 3 times asked the lead worker where the resident was. The lead worker was showering a resident, went out the door, looked both ways, came back in and went back to the resident left in the shower. The third staff had only been employed for 5 hours and did not appear to be involved. All have denied turning off the alarm during police interviews, but it was not still ringing at 5:45 AM when the nurse came in and when the resident search began at 6:45 AM. The Alarm panel was checked and found to be in perfect working order. 4) The staff neglected to ensure the safety of the residents prior to re-setting the alarm. 19. The above actions or inactions are a violation of Section 400.428, Florida Statutes, which requires the facility to maintain a safe and decent living environment for all residents, free from abuse and neglect. 20. The above referenced violation constitutes the grounds for the imposed Class II deficiency in that it directly threatened the physical or emotional health, safety, or security of the facility’s residents. Pursuant to Section 400.419(1) (b), Florida Statutes, the Agency is authorized to impose a fine in the amount of one thousand dollars ($1,000). 21. Pursuant to Section 400.419(9), Florida Statutes, AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint or for monitoring visits conducted under 400.428 (3) (c) to verify the correction of the violations. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following: 1. Make factual and legal findings in favor of the the Agency on Count I, Count II and Count III; 2. Impose a fine and survey fee in the amount of four thousand dollars ($4,000) for the violations cited in Count I, Count II and Count III against the Respondent, pursuant to Sections 400.419(1) (b) and 400.419(9), Florida Statutes; and 3. Any other general and equitable relief as deemed appropriate. The Respondent 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 Explanation of Rights (one page) and Election of Rights (two pages). All requests for hearing shall be made to the attention of Katrina D. Lacy, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Hehe) Spee Katrina D. Lacy, Esqui/re AHCA ~ Senior Attorne Fla. Bar No. 0277400 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7000 0520 0016 6299 0485, to CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on Kaban? DO Shee Katrina D. Lacy, paguive October XA, 2002. Copies furnished to: CT Corporation System Registered Agent for Alterra Clare Bridge of West Melbourne 7199 Greenboro Drive Melbourne, FL 32904 (Certified U.S. Mail) Administrator Alterra Clare Bridge of West Melbourne 7199 Greenboro Drive Melbourne, FL 32904 (U.S. Mail) Katrina D. Lacy AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330G St. Petersburg, Fl 33701 Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Alberta Granger AHCA, Assisted Living Facilities 2727 Mahan Drive, Bldg #3, MS Code #30 Tallahassee, Florida 32308 (Interoffice Mail) 12

Docket for Case No: 02-004748