STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, 0% Of b& AHCA NO: 2001048451 vs. TAMPA MEDICAL ASSOCIATES, INC., d/b/a MARINER HEALTH OF TAMPA, 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 TAMPA MEDICAL ASSOCIATES, INC., d/b/a MARINER HEALTH OF TAMPA (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Ten Thousand Dollars ($10,000) pursuant to Sections 400.102(1) (a) and (dad), 400.121(1), and 400.23(8) (b), Florida Statutes. 2. The Respondent was cited for the deficiencies noted below during the annual visit conducted on or about July 27, 2001. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4, Venue lies in Hillsborough County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28, Florida Administrative Code. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 3117 West Gandy Boulevard, Tampa, Florida 33611. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PROVIDE CARE AND SERVICES FOR INCONTINENCE VIOLATING 59A-4.1288, FL. ADMIN. CODE., INCORPORATING BY REFERENCE 42 CFR 483.25 (d) (2) CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. Based on resident record reviews and interviews the respondent failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible thereby being in violation of Fl. Admin Code R.59A-4.1288 incorporating by reference 42 CFR 483.25 (d) (2). 9. The particular findings regarding this deficiency include a./ Resident #11 was admitted to the facility in February 2000 as continent of bowel and bladder. On May 9,2001 the resident suffered several falls, which required overnight hospital evaluation. Upon return to the facility the resident was assessed on May 10, 2001 as being incontinent of bowel and usually continent of urine. On May 24, 2001 another assessment was completed on the resident which found the resident incontinent of both bowel and bladder. Interview with the Unit Manager on 7/25/01 revealed that the resident should have had a bowel and bladder reassessment since the initial one in February 2000. No individualized care plan was completed to assist in maintaining or improving continence. b./ Resident #23 (closed record review) was admitted from the hospital to the facility on 4/6/01 with a foley catheter in place. On 4/12/01 a progress note signed by the ARNP planned to discontinue the foley catheter. No documentation was found in the closed chart that the facility followed the policy for Indwelling Catheter Removal. On 4/16/01 progress notes from the nursing staff stated that the ARNP gave new orders. There was no documentation in the nursing notes that the foley catheter was reinserted as the ARPN had ordered. There was no documentation that the resident had a bladder elimination assessment when the foley catheter was removed on 4/13/01. c./ On February 14, 2001 Resident #20 was admitted to the facility. The resident had undergone genitourinary surgery approximately eight months prior to admission which resulted in an infection. The initial nursing assessment on February 14, 2001 found the resident to be continent of bowel and frequently incontinent of bladder. The resident, who was assessed as having no memory problems or communication difficulties, advised the surveyor that he/she was incontinent at night. Staff interview with the Unit Manager on 7/26/01 revealed that the bladder and bowel assessment had not been done on this resident contrary to facility policy. No individualized care plan had been prepared to assist the resident in improving continence at night. 10. The above referenced violation constitute the grounds for the one (1) imposed Class II deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under $400.022(3), §400.102(1) (a) (d), §400.121(1), and §400.23(8) (b), Florida Statutes. COUNT II RESPONDENT LACKED SUPERVISION AND CARE PLAN REVISIONS TO PREVENT FALLS; VIOLATING 59A-4.1288, FL. ADMIN. CODE., INCORPORATING BY REFERENCE 42 CFR 483.25 (h) (2) CLASS II DEFICIENCY 11. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 12. Based on resident record reviews and interviews the respondent failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Record review for Resident #5 revealed that the facility did not provide the necessary interventions to prevent falls and behaviors requiring monitoring and supervision to prevent injury. Resident #5 sustained a laceration on 3/17/01 requiring treatment at the Emergency Room. The facility had not assessed or revised the plan of care to avoid injury to resident even though the facility was on notice that resident had exhibited self endangerment behaviors before 3/17/01. 13. The above referenced violation constitute the grounds for the one (1) imposed Class IT deficiency and for which a fine of Five Thousand Dollars ($5,000) is authorized under $400.022(3), §400.102(1) (a) and (qd), §400.121(1), and §$400.23(8) (b), Florida Statutes. CLAIM FOR RELIEF SS RE WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Counts I and ITI; B. Impose a total fine of Ten Thousand Dollars ($10,000) for the violations cited in Counts I and II, against the respondent under §400.102(1) (a) and (d), §400.121(1), and $400.23(8) (b), Florida Statutes; Cc. Assess costs related to the investigation and prosecution of this case pursuant to $400.121(2) Florida Statutes, and D. All other general and equitable relief allowed by law. NOTICE TAMPA MEDICAL ASSOCIATES, INC., d/b/a MARINER HEALTH OF TAMPA 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 (one page). All requests for hearing shall be made to the attention of Eileen O’Hara Garcia, Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Drive, North, Sebring Building, Suite 330D, 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, ra ig Ura Chg Eileen O’Hara Garcia, Eg4uire AHCA - Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive, North Sebring Building, Suite 330D St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (FAX) I HEREBY CERTIFY that a copy hereof has been furnished to C T Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324, U.S. Certified Mail, Return Receipt No.7002 2030 0002 7109 5431, and Barbara Lawall, Administrator, Mariner Health of Tampa, 3117 West Gandy Blvd., Tampa, Florida 33611, U.S. Mail on November A7E a002. O Bileen O’Hafa Garcia, Esquire Copies furnished to: C T Corporation System Registered Agent for Mariner Health of Tampa 1200 South Pine Island Road Plantation, Florida 33324 (U.S. Certified Mail) Barbara Lawall, Administrator Mariner Health of Tampa 3117 West Gandy Boulevard Tampa, Florida 33611 (U.S. Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 Molly McKinstry, Long Term Care Agency for Health Care Administration 2727 Mahan Drive, Bldg #1, MS Code #33 Tallahassee, Florida 32308 (Interoffice Mail) Eileen O’Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive, North Sebring Building, Suite 330D Saint Petersburg, Florida 33701

Docket for Case No: 03-000166