STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, AHCA NO. 2002045766 62-d151 Petitioner, vs. AGE INSTITUTE OF FLORIDA, INC. d/b/a CLEARWATER CENTER, Respondent. 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 sometimes 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 to assign a conditional license to Clearwater pursuant to Section 400.23, Florida Statutes (2001), and to assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). The original conditional license is attached hereto as Exhibit “A”. JURISDICTION AND VENUE 2. The Agency has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2001). 3. venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES 4. 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. 5. 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. 6. 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 EFFECTIVE JUNE 29, 2002, THE AGENCY ASSIGNED A CONDITIONAL LICENSURE STATUS TO CLEARWATER BASED UPON THE DETERMINATION THAT CLEARWATER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) CLASS I DEFICIENCY AT THE MOST RECENT SURVEY OF JUNE 29, 2002. § 400.23(7), Fla. Stat. (2001) CLASS I DEFICIENCY 7. The Agency realleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 8. On or about June 29, 2002 the Agency conducted a survey at Clearwater. The Agency cited Clearwater for a class I deficiency based on the findings below involving resident #3. RESIDENT #3 9. 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. 10. 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. 41. 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 cardiopulmonary resuscitation (“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 According to CNA #1, the RNS did (Emergency Medical Services). not perform CPR on resident #3 and did not instruct other staff members to do so. 12. 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. 13. 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. 14. Clearwater failed to provide adequate and appropriate health care and protective and support services to resident #3. 15. Clearwater failed to develop or implement policies and 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; or (d) policies and procedures on resident rights. 16. 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 and 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. 17. 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). COUNT ITI EFFECTIVE JUNE 29, 2002, THE AGENCY ASSIGNED A CONDITIONAL LICENSURE STATUS TO CLEARWATER BASED UPON THE DETERMINATION THAT CLEARWATER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) CLASS I DEFICIENCY AT THE MOST RECENT SURVEY OF JUNE 29, 2002. § 400.23(7), Fla. Stat. (2001) CLASS I DEFICIENCY 18. The Agency realleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 19. On or about June 29, 2002 the Agency conducted a survey at Clearwater. The Agency cited Clearwater for a class I deficiency based on the findings below. 20. 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- (“DNR”) order or if full resuscitation was to be resuscitate 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 his or her room. 21. 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. 22. On or about June 29, 2002 an Agency surveyor interviewed a certified nursing assistant (“CNA #1”). 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. 23. 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. 24. 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. 25. 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. 26. Clearwater failed to develop or implement policies or procedures on advance directives, which ensured the prompt identification of residents who had advance directives. e @ 27. Clearwater failed to educate or adequately educate its staff on advance directive policies or procedures. 28. 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. 29. 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). COUNT III EFFECTIVE JUNE 29, 2002, THE AGENCY ASSIGNED A CONDITIONAL LICENSURE STATUS TO CLEARWATER BASED UPON THE DETERMINATION THAT CLEARWATER WAS NOT IN SUBSTANTIAL COMPLIANCE WITH APPLICABLE LAWS AND RULES DUE TO THE PRESENCE OF ONE (1) CLASS I DEFICIENCY AT THE MOST RECENT SURVEY OF JUNE 29, 2002. § 400.23(7), Fla. Stat. (2001) CLASS I DEFICIENCY 30. The Agency realleges and incorporates by reference paragraphs one (1) through six (6) above as if fully set forth herein. 31. 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. 32. 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”). 33. 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. 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 resident #3 and did not instruct other staff members to do so. 34. On or about June 29, 2002 an Agency surveyor interviewed CNA #2. CNA #2 worked the 7:00 a.m. to 11:00 p.m. shift 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 11 (15) to twenty (20) minutes. CNA #2 said room for about fifteen he was curious as to why the RNS left the resident’s room. CNA #2 said that at no time was CPR administered to resident #3 by the RNS or by Clearwater staff. 35. 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. 36. 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. 37. 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." 38. 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. 39. 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). 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, II and III; 2) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001); 3) Uphold the issuance of the conditional license, attached hereto as Exhibit “A”; and 4) Grant any other legal and equitable relief as deemed necessary in the furtherance of justice. DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, Clearwater shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. NOTICE 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. Aix 0 Dew et 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 CERTIFICATE OF SERVICE I HEREBY CERTIFY that the original administrative complaint and the original conditional license attached thereto as Exhibit “A” has been furnished via U.S. Certified Mail, Return Receipt Requested (# VOO4FSTS/2ZI40050 32355) to Sal White, d/b/a Clearwater Administrator, Age Institute of Florida, Inc. Center, 1270 Turner Street, Clearwater, Florida 33756, and a true and correct copy of the administrative complaint and Exhibit “A” has been sent via U.S. Certified Mail, Return Receipt Request, (D106 4STS (294-2050 3302 ) 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. Aer @. Dower Lori C. Desnick, Esquire Exhibit A CONDITIONAL LICENSE License # SNF1091096; Certificate #8877 Effective Date: 06/29/2002 Expiration Date: 01/31/2003

Docket for Case No: 02-004751