CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, 0 2% _ () (7 Be Petitioner, AHCA NO: 2002045644 vs. FOUNTAINS SENIOR PROPERTIES OF FLORIDA, INC., d/b/a SPRINGS AT LAKE POINTE WOODS, 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 FOUNTAINS SENIOR PROPERTIES OF FLORIDA, INC. d/b/a SPRINGS AT LAKE POINTE WOODS, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1) This is an action to impose administrative fines totaling TEN THOUSAND DOLLARS ($10,000) pursuant to §§ 400.022(1)(1), 400.022(3), 400.102(d), 400.102(1)(d), 400.121(2), 400.23(7)(b) and 400.23(8), Fla. Stat. 2) The Respondent was cited for the deficiencies set forth below as a result of survey conducted on or about July 11, 2002. The deficiencies cited in the July 11, 2002 survey were repeat deficiencies from the survey conducted on or about August 8, 2001. JURISDICTION AND VENUE 3) AHCA has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. Page 1 of 15 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 4) Venue lies in County Name County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 Fla. Admin. 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 skilled nursing facility located at 7848 BENEVA ROAD, SARASOTA, FLORIDA, 34238. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. Its license number is 1468096 effective through 06/30/2003 and the certificate number is 9124. COUNT I RESPONDENT FAILED TO ENSURE THAT EACH RESIDENT RECEIVED AND 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. FLA ADMIN CODE R 59A-4.1288 (ADPOTING BY REFERENCE 42 CFR §483.25), §§ 400.022(1)(1), 400.022(3), 400.102(d), 400.102(1)(d), 400.121(2), and 400.23(8)(b), FLA STAT CLASS I REPEAT DEFICIENCY 7) AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8) On or about July 11, 2002, AHCA conducted a survey of the Respondent. Findings included: a) Based on observations, interviews of the resident, facility staff and resident's physician, record review and review of current standards of nutritional care, the facility failed to provide appropriate coordination of services in the care rendered for one (Resident #15) of 20 sampled residents as evidenced by: i) An incomplete diet order regarding fluid restriction sent from nursing to dietary upon admission. ii) Failure of the facility's CDM (Certified Dietary Manager) and Consultant RD (Registered Dietitian) to timely seek physician clarification of an inappropriate diet order change on 5/17/02. Page 2 of 15 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 iii) Failure of the RD to aggressively consult with the physician regarding current standards of nutritional care of Chronic Renal Insufficiency and CHF (Congestive Heart Failure). iv) Failure to educate wait staff of Resident #15's fluid restriction resulting in a worsening of the resident's edema and CHF as evidenced by a weight gain of 38 pounds from 5/22/02 to 7/9/02 and an increase in Blood Urea Nitrogen from 59 obtained on 4/17/02 while the resident was in the hospital to 88 on 5/30/02 and a diagnosis rendered by the physician on 7/10/02 of Severe End-Stage Cardiomyopathy with no hope of significant improvement and an order for a Hospice consult. Per the facility's MAR (Medication Administration Record) for the month of July, the resident requested and received Darvocet-N 100 on 12 occasions during the first 9 days of the month for leg pain resulting from increased edema. b) Resident #15 was admitted to the facility from a hospital on 5/06/02 with diagnoses including Cardiomyopathy, CHF (Congestive Heart Failure), Chronic Renal Insufficiency, Ascites, and Respiratory Abnormalities. The hospital H & P (History and Physical) dated 4/17/02 (admission date to hospital) states that the resident has severe Cardiomyopathy, Ischemic with a recent ejection fraction of approximately 15 percent. The H&P notes that the patient has one plus edema of extremities and Ascites. Laboratory work reveals electrolytes normal except for Blood Urea Nitrogen of 59, Creatinine of 2.2. c) When Resident #15 was admitted to the facility, pertinent medications included the diuretics, Demadex and Aldactone. The admitting diet order for this resident was 2 Gram Sodium with a fluid restriction of 2000 ml (milliliters) per 24 hours further specified as 665 ml per 8 hour period. The Diet Order form sent from nursing to dietary specified 2 Gm Sodium and 2000 ml per 24 hour fluid restriction with no information that the restriction of fluids also included the 8 hour provision. d) The Nutrition Risk Assessment completed by the facility's CDM (Certified Dietary Manager) on 5/13/02 and co-signed by the facility's Consultant RD (Registered Dietitian) on 5/15/02 records a Page 3 of 15 e) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 weight of 187 pounds with a usual body weight of 180 pounds. The assessment recorded the fluid restriction as 2000 cc per 24 hours and did not specify the further physician instructions of 665 ml per 8 hours. The Dietary Interview/Pre-Screen form completed by the CDM on the same date specified that the resident would receive 1200 ce for dietary and 800 cc from nursing with dietary providing 720 cc of fluid at breakfast, 240 cc of fluid at lunch and 240 cc of fluid at dinner. With this distribution, dietary was exceeding the 8 hour (7 to 3 shift) allowance of fluids by providing 960 cc in less than 8 hours. The 2 Gram Sodium restriction was noted. Laboratory results obtained on 5/09/02 were noted on the assessment: Bun (Blood Urea Nitrogen) of 80 (increased from 59 with a desirable range of 6 to 22), Creatinine of 3.0 (increased from 2.2 with a desirable range of 0.5 to 1.2). The labs of 5/09/02, also reflected that the Potassium was 4.6 (desirable range of 3.5 to 5.1). In response to these lab values, the physician ordered that the Demadex be decreased to 40 mg. in the AM and 20 mg. in the PM. He also ordered that the lab work be repeated on 5/13/02. The lab work ordered to be completed on 5/13/02 was not available in the resident's record. The record did contain a telephone order of 5/16/02, which read as follows: "D/C (discontinue) Aldactone, Diet Low Potassium, CBC (complete blood count), SMA-7 (lab work) in one week..." The lab work ordered for 5/23/02 was not available in the resident's record. However, a telephone order was written on 5/23/02 that the Demadex was to be decreased to 40 mg. each day and that the lab work was to be repeated in one week. The RD entered a note into the record on 5/22/02 noting a current weight of 173 pounds with a 14 pound decrease since admission (from 187 pounds). The RD noted that the diet was Low Potassium with no acknowledgement of the fluid restriction nor any clarification requested of the Sodium restriction, which had been discontinued by the facility on 5/16/02 even though the history of renal failure and edema was noted by the RD. The RD further documents that a supplement of Resource 2.0, 3 oz. (90 cc) had been ordered per recommendation of the CDM because of the Page 4 of 15 8) h) i) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 weight loss (with no recognition by the CDM that the weight loss could be attributed to a decrease in edema) to be given three times daily on 5/17/02 with intake estimated at 225 cc per day. There was no documentation to indicate that the 225 cc was within the ordered fluid restriction. Laboratory results of 5/30/02, present in the medical record revealed that the BUN had increased to 88 while the Creatinine had decreased slightly to 2.9. The potassium was within desirable range at 3.9. The physician responded to these labs by decreasing the Demadex to 20 mg. each day and continuing daily weights with an order to be notified for a weight gain equal to or greater than 2 pounds. The resident's weight on this date was recorded as 178 pounds, an increase of 5 pounds since 5/22. The physician also ordered that lab work be repeated in one week. The results of the lab work ordered for completion on 6/06 were unavailable in the record. A note by the CDM on 6/05 did state that the Resident had 1+ edema to bilateral lower extremities and was requesting soup for lunch. The RD entered a note into the record on 6/12/02, which addressed the labs of 5/30 with no mention of the labs ordered for 6/07. The current weight was noted to have increased to 187 pounds, an increase of 9 pounds in one week. The RD note contained the following recommendations: (1) A diet order clarification to read No Added Salt, Low Potassium, (2) Verification that the fluid restriction was still needed, and (3) A reduction of the supplement to 3 oz twice daily. il) These recommendations were not communicated to the physician by the RD until faxed on 6/20/02. The physician responded by asking the following questions which were faxed to the facility on the same date: "Does he have Pedal Edema? Does he have SOB (Shortness of Breath)? Where F/U SMA-7 (the ordered lab work) from 6/07/02?" On 6/25/02, the physician entered a note into the medical record indicating that the resident's weight was now 202 (a gain of 29 pounds since 5/22), that the resident had increased shortness of breath, and pedal edema. His plan was to increase the Demadex to 60 mg. daily for 3 days, then Page 5 of 15 D k) ) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 40 mg. daily after that. He ordered additional labs to be completed in 4 days with the results faxed to his office. The next note by the RD was entered into the record on 7/01/02. The resident's weight was documented in the note to be 202 pounds. The note further documents that the physician did not approve the recommendations of 6/20/02 by the RD. Lab work was completed on 7/01, which showed the BUN to be 50 and the Creatinine to be 2.4. He ordered the labs to be repeated in 2 weeks. On 7/07 the physician ordered Lasix 40 mg. 1 time dose (The resident's weight had been recorded to have increased to 205 on 7/02). On 7/08, the physician entered a note into the record that documented increased weight and swelling of the legs. The weight is recorded by the physician to be 216 pounds. 2 - 3+ edema bilaterally is documented with the diagnosis of End-stage Cardiomyopathy and a plan to increase diuretics. The Demadex was increased to 80 mg. daily and fluids were further restricted to 1000 ce per 24 hours. m) On 7/03, the RD entered a note into the record stating that she still concurred with her previous recommendations that had been declined by the physician and that she would monitor and follow- up routinely. On the third day of the survey 7/10, the physician responded to a request by the facility that he visits the resident regarding concerns of increased weight and edema. His note documents that the resident is in Severe End-Stage Cardiomyopathy with an ejection factor of 10%. He documents the Pre-Renal Azotemia secondary to decreased cardiac output. He further states that the facility has been keeping him well aware of status. He documents the resident's edema as 1+ arm, 1-2+ sacral, and 2-3 legs with weeping vesicles. The abdomen has 2+ Ascites. His weight has decreased from 216 to 211. The physician states that the edema is secondary to Cardiomyopathy and CHF (Congestive Heart Failure) with no hope of significant improvement. The plan is to increase the Demadex, but prognosis is very poor. The physician clarified the diet order to be 2 Page 6 of 15 0) p) q) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 Gram Sodium, Low Potassium, 1000 cc/24 hours fluid restriction and increased the Demadex to 80 mg. twice daily. He also ordered a Hospice consult. Resident #15 was observed during the noon meal to receive a Low Potassium diet. He was served a 12 oz glass of water, a 4 oz. glass of apple juice, and was offered a glass of tea by the wait staff. When staff started to salt his food, he stopped the staff person stating, "I don't want any extra salt." The stuffing served to him was an instant stuffing mix per interview with the Dietary Manager at 11:45 A.M. on 7/10/02. Taste test by the surveyor revealed a salty product. The resident stated during the noon meal that he was not feeling well because he was all "puffed-up” with fluid. He stated that his leg and hands were so tight that they hurt. The alert resident stated that he knew he should be on a salt-restricted diet, but that the facility continued to serve him salty foods. Observation of the resident's room at 12:30 P.M. on 7/10 revealed, 2, 8 oz. bottles of water (1 of which was half empty) and a 4 oz. cup of water. (20 ounces of water is equal to 600 cc.) On 7/08/02, the fluid restriction had been adjusted by the physician to allow only 1000 cc in a 24 hour period. Current standards of practice for nutritional interventions for Renal Insufficiency as outlined in the 2002 Edition of The Florida Diet Manual specify the following: “Recent studies have suggested that a diet low in protein and phosphorus may slow or prevent the progression of renal disease...Protein restriction is the major component of nutritional management for Chronic Renal Insufficiency. The current recommendation is 0.6 gm per kg. of IBW (Ideal Body Weight)... The usual sodium prescription ranges between 1 to 3 gm per day.” The diet manual further specifies: “The nutrition therapy for congestive heart failure aims to decrease the sodium retention, edema and cachexia that often accompany this disorder.” The recommended level of sodium restriction is 2 gm or less for patients with severe heart failure. At no time did the facility's Consultant RD recommend a diet that incorporates these standards of nutritional care. Page 7 of 15 9) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 r) The physician's office was contacted on 7/15/02 for a response to the 2 Gram Na diet order. The spokesperson for the physician stated, "The doctor wants him on a 2 Gram Na diet." Based upon the forgoing, the Respondent violated 42 CFR §483.25, which requires the Respondent to 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. Fla. Admin Code R. 59A-4.1288 implements §§ 400.102, 400.121(2), and 400.23 Fla. Stat. and incorporates by reference 42 CFR 483.25. The Respondent also violated § 400.022(1)(1) and 400.022(3) Florida Statutes, which require the Respondent to ensure the resident’s right to receive adequate and appropriate health care and protective and support services, 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. 10) The Respondent was previously cited a Class II deficiency in a survey conducted on or about August 8, 2001. 11) The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which the imposition of a conditional license is authorized pursuant to §§ 400.102(1)(d), and 400.23(7)(b), Fla. Stat. CLAIM FOR RELIEF FOR COUNT I 12) WHEREFORE, AHCA requests this Court to order the following relief: a) Make factual and legal findings in favor of AHCA on Count I, b) Impose a fine of FIVE THOUSAND DOLLARS ($5,000) for the violation cited in Count I against the Respondent under Fla. Admin Code R 59A-4.1288 (adpoting by reference 42 CFR §483.25), §§ 400.022(1)(1), 400.022(3), 400.102(d), 400.102(1)(d), 400.121(2), and 400.23(8), Fla. Stat. Page 8 of 15 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 COUNT It RESPONDENT FAILED TO ENSURE THAT EACH RESIDENT RECEIVED AND 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, INCLUDING THE PROVISION OF ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS.. FLA ADMIN CODE R 59A-4.1288 (ADPOTING BY REFERENCE 42 CFR §483.25), §§ 400.022(1)(), 400.022(3), 400.102(1)(d), 400.121(2), and 400.23(8)(b), FLA STAT 13) AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 14) On or about July 11, 2002, AHCA conducted a survey of the Respondent. Findings included: 15) Based on observations, interviews of facility staff and family, and record review, the facility failed to provide needed supervision of and assistance with ambulation, failed to provide the needed equipment (rolling walker) for safe ambulation that was identified on the admission RAI (Resident Assessment Instrument) and failed to timely assess the cause of multiple falls and appropriately revise interventions for 1 (Resident #1) of 10 active sampled residents who were identified as experiencing falls resulting in multiple injuries to this severely cognitively impaired resident including a fracture of the left distal radius. a) Resident #1 was admitted to the facility on 1/14/02 with diagnoses including Manic Depression and Hypothyroidism. The RAI (Resident Assessment Instrument) completed 1/28/02, identified this resident as being admitted due to decline in cognition and requiring cueing and supervision with ADLs (Activities of Daily Living). “Resident is ambulatory with walker and...wanders without safety awareness.” She is coded as being severely cognitively impaired. The RAI identified unsteady balance. However, the RAI did not identify any devices under Section G.5. “Modes of Locomotion.” The RAP (Resident Assessment Protocol) for falls is as follows: “Res (Resident) has risk for falls based on unsteady gait and predilection to roam in the hallways...Res reminded to call for assist and not ambulate independently without supervision. Falling Star Page 9 of 15 b) c) qd) e) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 Program, Thera (Therapy) Eval. (Evaluation) of gait and balance and redirection used.” The RAI identified the resident to be independent in transfers while requiring supervision with locomotion. The resultant Care Plan of 2/04/02 identified the concern of “Potential for fall d/t (due to) independent ambulation with decline in cognition.” The following 5 approaches were listed on the Care Plan on 2/04/02: “1) Falling star program, 2) Monitor for appropriate footwear, 3) Shower/bath assistance, 4) Cued and reoriented as needed, and 5) PT (Physical Therapy) to screen for gait and balance level.” Review of nursing notes dated 2/12/02, revealed that the resident was found to have an ecchymotic area of unknown origin to the right post forearm measuring 8 cm. X 5 cm. On 2/14/02, the approach of “apply bed alarm if noted attempts to get OOB (out of bed) was added to the care plan.” Nursing notes of 3/06/02, reveal the resident was found sitting on the floor in front of the bathroom. An incident report was completed with a corrective action of having the resident wear flat shoes with low heels. However, this approach was not added to the Care Plan. Nursing notes of 4/27/02, document that the resident's left arm is swollen and discolored. The resident was reported to voice discomfort when the arm was touched. Ice was applied and an order for an x-ray of the left wrist and left arm was obtained. The results were negative. An investigation conducted by the facility revealed that the resident had lost her balance while being assisted into bed by her husband, had fallen and struck her left arm against a wastepaper basket. The corrective action plan of the facility was to instruct the husband to call for assistance when assisting his wife. However, the MDS (Minimum Data Set) completed on 4/24/02 as a quarterly assessment specifies the resident to be independent with transfers. No additional approaches were added to the Care Plan as a result of this assessment even though the assessment identifies recent falls. Page 10 of 15 f) g) h) D CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 Nursing notes of 5/11/02, document a large ecchymotic area (bluish purple color) on right outer gluteal. The note states that the resident ambulates “per self’ and is unable to give any information regarding the injury. There was no documentation that further investigation into the cause of the injury was conducted by the facility. No additional approaches were added to the Care Plan. On 5/13/02, an order was obtained for an x-ray of the resident's left wrist due to swelling and pain. The x-ray was negative for fracture. On 5/18/02, the following approach was added to the Care Plan for falls: “Use physical assist at arm and elbow to prevent stumbling. Remind (Resident) not to get out of bed unassisted.” The medical record of this resident contains a copy of a fax sent to the attending physician on 5/18/02, which relates that the resident was found on the floor at 4:15 A.M. next to the bed with abrasions on right knee and right side forehead at eyebrow with edema. Nursing notes of the same date confirm that the resident's husband was notified of the fall and of the injuries to the resident's head and knee, The note further identifies an injury to the resident's 4th finger of the left hand, which is described as swollen and purple. The physician was notified and ordered a low bed. The resident was taken by her husband to the emergency room for an x-ray and a CAT scan. The results of both were negative. The resident's husband of 59 years visits twice daily. During interview at noon on 7/10/02, the husband, who expressed that it was not necessary to safeguard his identity, stated that his wife had been x-rayed due to injuries on three occasions. He related that he and his daughter who is a physician were concerned about the persistent swelling in his wife's arm and had taken her to an Orthopedic Surgeon for a third x-ray. This third x-ray had confirmed a fracture. The results of this consultation, which had taken place on 6/11/02, were found in the resident's record and stated that the resident had fallen in early May and initial x-rays were read as negative. The consult explains that the resident's husband was concerned due to persistent swelling. The Radiological Page 11 of 15 k) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 Data is as follows: “Plain films of the wrist demonstrate a healed distal radius fracture in near anatomic alignment.” The Impression reads: "Clinical and radiographically healed left distal radius fracture." The physician further explained, “I told her and her husband to expect some soft tissue swelling for another month or two.” Interview with the facility's Administrator and Director of Nursing on 7/10/02, revealed that neither were aware of the reported fracture. The resident's record confirms that an additional fall happened on 6/10/02. No explanation was given other than the resident was found on the floor. m) On 6/13/02, an approach of “wheelchair, instructed in use” was added to the Care Plan. At this n) 0) point, after multiple falls and injuries, a request was sent to PT (Physical Therapy) for a screen for the use of a walker. The findings of the screen conducted one week later on 6/17 confirm that the resident requires assistance and supervision with cues in all mobility and ADLs secondary to cognitive impairment and is able to ambulate with rolling walker. The PT screen documents that both nursing and nursing assistants were instructed to monitor use and safety. A follow-up was conducted by PT on 6/19 as follows: “Nursing reports pt (patient) doing well with walker. Still requires S (Supervision) with or without walker secondary to decreased cognition.” During the first three days of the survey the resident was observed to be ambulating around the hallways of the facility and wandering into resident rooms without benefit of a rolling walker or wheelchair and without supervision or assistance. A wheelchair was noted to be pushed against the wall in the resident's room during these 3 days. No rolling walker was in the resident's room during these observations. During interview of the husband on 7/10/02 at noon, the husband stated that he did not know what happened to the walker. He stated that he remained worried about his wife falling and that he let her use his walker (observed to be a 3-wheeled rolling walker) to ambulate when he was visiting his wife at the facility. He stated, “It's my fault; I should have asked about the walker.” Page 12 of 15 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 p) During interview on 7/11/02, the facility's Administrator reported to the surveyor that the Director of Nursing had stated that she thought the husband was using the resident's walker. q) Interview with the Physical Therapy at 9:45 A.M. on 7/11, confirmed that the husband's 3-wheeled walker was quite different from the facility's rolling walkers. Observation of the resident during the morning hours of 7/11/02 revealed that she was in a wheelchair. One of the facility's 2- wheeled rolling walkers was present in the resident's room. 16) Based upon the forgoing, the Respondent violated 42 CFR §483.25, which requires the Respondent to 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. The care that this regulation requires includes the provision to each resident of adequate supervision and assistance devices to prevent accidents. Fla. Admin Code R. 59A-4.1288 implements §§ 400.102, 400,121(2), and 400.23 Fla. Stat. and incorporates by reference 42 CFR 483.25. The Respondent also violated § 400.022(1)(1) and 400.022(3) Florida Statutes, which require the Respondent to ensure the resident’s right to receive adequate and appropriate health care and protective and support services, 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. 17) The Respondent was previously cited for a Class II violation on a survey that was conducted on or about August 8, 2001. 18) The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of FIVE THOUSAND DOLLARS ($5000) is authorized under §§ 400.102(1)(d), 400.121(2), and 400.23(8), Fla. Stat. CLAIM FOR RELIEF FOR COUNT II WHEREFORE, AHCA requests this Court to order the following relief; a) Make factual and legal findings in favor of AHCA on Count II, Page 13 of 15 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 b) Impose a fine of FIVE THOUSAND DOLLARS ($5,000) for the violation cited in Count I against the Respondent under Fla. Admin Code R 59A-4.1288 (adpoting by reference 42 CFR $483.25), §§ 400.022(1)(1), 400.022(3), 400.102(d), 400.102(1)(d), 400.121(2), and 400.23(8), Fla. Stat. NOTICE 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 (one page). All requests for hearing shall be made to the attention of Joanna Daniels, Assistant General Counsel, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, FL 32308. 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, Bonne Sbeale Joanna Daniels FL Bar #0118321 Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, FL 32308 (850) 922-5873 Fax (850) 413-9313 Page 14 of 15 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0927 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Administrator, SPRINGS AT LAKE POINTE WOODS, 7848 BENEVA ROAD, SARASOTA, FLORIDA, 34238, Return Receipt No. 7106 4575 1294 2050 0927 by U.S. Certified Mail, on December IQ, 2002. Z, Limitle JOA emcee. Assystint General Counsé Copies furnished to: Wendy Adams Joanna Daniels Agency for Health Care Administration Agency for Health Care Administration 2727 Mahan Drive, MS #3 2727 Mahan Drive, MS #3 Tallahassee, FL 32308 Tallahassee, FL 32308 (Interoffice Mail) JD/ghm Page 15 of 15 eer a a HEALTH CARE FINANCING ADMINISTRATION ‘STATEMENT OF DEFICIENCIES (XE) PROVIDER/SUPPLIER/CLIA FORM APPROVED 2567-L (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY Use F309 for quality of care deficiencies not covered by s483.25(a)-(m). This Requirement is not met as evidenced by: Based on observations, interviews of the resident, facility staff and resident's physician, record review and review of current standards of nutritional care, the facility failed to provide appropriate coordination of services in the care rendered for one (Resident #15) of 20 saampled residents as evidenced by: 1) An incomplete diet order regarding fluid restriction sent from nursing to dietary upon admission, 2) Failure of the facility's CDM (Certified Dietary Manager) and Consultant RD (Registered Dietitian) to timely seek physician clarification of an inappropriate diet order change on 5/17/02. 3) Failure of the RD to ageressively consult with the physician regarding current standards of nutritional care of Chronic Renal Insufficiency and CHF (Congestive Heart F: ailure). 4) Failure to educate wait staff of Resident #15's fluid Testriction resulting in a worsening of the resident's edema and CHF as evidenced by a weight gain of 38 CMS-2567L ATG021199 AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED B. WING 105567 _ 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ‘INGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D i PROVIDER'S PLAN OF CORRECTION (x) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG OR 1.8C IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATEEDEFICIENCY AT + ta i => “. . F 246] Continued From page 4 F246 | Vy Bw t ; oe ts hisherself. C4. - : 3) All residents will be screene BICOM for positioning proper table height, e' vitonmrent of 13; needs on admission and monthly there ‘after. Unit Sr S9A~4.1288 manager will supervise and monitor equire’ dining x. Class [II process. oh “ Correction Date: 8/11/02 Gy 4) D.O.N. to monitor report to Quarterly QA‘: | F 309] 483.25 QUALITY OF CARE F309 | tail . 1) Resident #15 MD re-assessed resident, | outtjo2 SS=G ; . completed a physician's progress note, and Each resident must receive and the facility must wrote new orders which included a new diet provide the necessary care and services to attain or order and fluid restriction. An immediate maintain the highest practicable physical, mental, and inservice was given to wait staff, Psychosocial well-being, in accordance with the 2) RD reviewed ail diet orders for completeness comprehensive assessment and plan of care. and appropriateness. Corrective measures were taken if waranted. The RD/CDM will call and fax/provide recommendations to MD daily for 2 days and document. If no response within 2 days, recommendation(s) will be submitted to the designated Nurse Supervisor. Those residents ona fluid restriction will be identified by indicating "fluid restriction” on their armband, All staff have been inserviced on the fluid restriction policy and Procedure. 3) The RD/CDM will identify those residents with history of Chronic Heart Failure, Chronic Renal Insufficiency, and/or Chronic Renal Failure upon admission and through the quarterly process. GFR (Glomuler Filtration Rate) or Creatinine Clearance will be calculated for those residents identified with Chronic Renal Insufficiency and/or Chronic Renal Failure, excluding those on dialysis or with muscle wasting, who are being treated for conservative management of Renal Disease. Significant findings will be communicated to MD. RD/CDM to conduct a Monthly diet audit for completeness and make any necessary corrections if warranted, 4) RD/CDM to monitor diet orders upon admission for completeness and appropriateness. RD/CDM to conduct a monthly diet audit and make any necessary corrections if warranted. A report will be Provided to the quarterly Qa. YXPS11 If continuation sheet 5 of 23 we nn ae FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION 2567-L STATEMENT OF DEFICIENCIES (X31) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED B. WING 105567 en 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE " *INGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (4D | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION | (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY| PREFIX (EACH CORRECTIVE ACTION SHOULD BE j COMPLETE TAG OR LSC IDENTIFYING INFORMATION) ; TAG |CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE | F 309) Continued From page 5 F 309 | | pounds from 5/22/02 to 7/9/02 and an increase in | | Blood Urea Nitrogen from 59 obtained on 4/17/02 while the resident was in the hospital to 88 on 5/30/02 and a diagnosis rendered by the physician on 7/10/02 of Severe End-Stage Cardiomyopathy with no hope of significant improvement and an order for a Hospice consult. Per the facility's MAR (Medication Administration Record) for the month of July, the resident requested and received Darvocet-N 100 on 12 occasions during the first 9 days of the month for leg | pain resulting from increased edema. ' The findings include: Resident #15 was admitted to the facility from a hospital on 5/06/02 with diagnoses including Cardiomyopathy, CHF (Congestive Heart F ailure), Chronic Renal Insufficiency, Ascites, and Respiratory Abnormalities. The hospital H & P (History and Physical) dated 4/17/02 (admission date to hospital) states that the resident has severe Cardiomyopathy, Ischemic with a recent ejection fraction of approximately 15 percent. The H&P notes that the patient has one plus edema of extremities and Ascites. Laboratory work reveals electrolytes normal except for Blood Urea Nitrogen of 59, Creatinine of 2.2. When Resident #15 was admitted to the facility, pertinent medications included the diuretics, Demadex | and Aldactone. The admitting diet order for this resident was 2 Gram Sodium with a fluid restriction of 2000 ml (milliliters) per 24 hours further specified as 665 ml per 8 hour period. The Diet Order form sent from nursing to dietary specified 2 Gm Sodium and 2000 m1! per 24 hour fluid restriction with no information that the restriction of fluids also included the 8 hour provision. The Nutrition Risk Assessment completed by the CMS-2567L ATGO21199 YXPSI1 If continuation sheet 6 of 23 FURM APPROVED facility's CDM (Certified Dietary Manager) on 5/13/02 and co-signed by the facility's Consultant RD (Registered Dietitian) on 5/15/02 records a weight of 187 pounds with a usual body weight of 180 pounds. The assessment recorded the fluid restriction as 2000 cc per 24 hours and did not specify the further physician instructions of 665 ml per 8 hours. The Dietary Interview/Pre-Screen form completed by the CDM on the same date specified that the resident would receive 1200 cc for dietary and 800 cc from nursing with dietary providing 720 cc of fluid at breakfast, 240 cc of fluid at lunch and 240 cc of fluid at dinner. With this distribution, dietary was exceeding the 8 hour (7 to 3 shift) allowance of fluids “by providing 960 cc in less than 8 hours. The 2 Gram Sodium restriction was noted. Laboratory results obtained on 5/09/02 were noted on the assessment: Bun (Blood Urea Nitrogen) of 80 (increased from 59 with a desirable range of 6 to 22), Creatinine of 3.0 (increased from 2.2 with a desirable range of 0.5 to 1,2). The labs of 5/09/02, also reflected that the Potassium was 4.6 (desirable range of 3.5 to 5.1), In Tesponse to these lab values, the physician ordered that the | Demadex be decreased to 40 mg. in the AM and 20 mg. in the PM. He also ordered that the lab work be j Tepeated on 5/13/02. The lab work ordered to be completed on 5/13/02 was not available in the resident's record. The record did contain a telephone order of 5/16/02, which read as follows: "D/C (discontinue) Aldactone, Diet Low Potassium, CBC (complete blood count), SMA-7 (lab work) in one week..." The lab work ordered for 5/23/02 was not available in the resident's record, However, a telephone order was written on 5/23/C2 that the Demadex was to be decreased to 40 mg. each day and that the lab work was to be repeated in one week, CMS-2567L ATGO21199 YXPS11 HEALTH CARE FINANCING ADMINISTRATION 2567-L ' STATEMENT OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ; COMPLETED B. WING 105567 —_ a 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE XUINGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 03) (BACH DEFICIENCY MUST BE PRECEEDED BY FULLREGULATORY| PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE Continued From page 6 F 309 If continuation sheet 7 of 23 we ne en ee ee bun ArrRUY cu HEALTH CARE FINANCING ADMINISTRATION 2567-L (X2) MULTIPLE CONSTRUCTION STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED B. WING a 105567 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE RINGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (xa) ID SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION {xs PREFIX |(EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY| PREFIX (EACH CORRECTIVE ACTION SHOULD BE i COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY: DATE 1 | : ~T F 309] Continued From page 7 F 309 The RD entered a note into the record on 5/22/02 noting a current weight of 173 pounds with a 14 pound : i decrease since admission (from 187 pounds). The RD | noted that the diet was Low Potassium with no acknowledgement of the fluid restriction nor any clarification requested of the Sodium restriction, which had been discontinued by the facility on 5/16/02 even though the history of renal failure and edema was noted by the RD. The RD further documents that a { supplement of Resource 2.0, 3 oz. (90 cc) had been ordered per recommendation of the CDM because of the weight loss (with no recognition by the CDM that the weight loss could be attributed to a decrease in edema) to be given three times daily on 5/17/02 with | intake estimated at 225 cc per day. There was no | documentation to indicate that the 225 cc was within the ordered fluid restriction. Laboratory results of 5/30/02, present in the medical record revealed that the BUN had increased to 88 while the Creatinine had decreased slightly to 2.9. The potassium was within desirable range at 3.9. The physician responded to these labs by decreasing the Demadex to 20 mg. each day and continuing daily weights with an order to be notified for a weight gain | equal to or greater than 2 pounds. The resident's | weight on this date was recorded as 178 pounds, an increase of 5 pounds since 5/22. The physician also ordered that lab work be repeated in one week. The results of the lab work ordered for completion on 6/06 were unavailable in the record. A note by the CDM on 6/05 did state that the Resident had 1+ edema to bilateral lower extremities and was requesting soup for lunch. The RD entered a note into the record on 6/12/02, which addressed the labs of-5/30 with no mention of the labs ordered for 6/07. The current weight was noted to have increased to 187 pounds, an increase of 9 pounds in one week. The RD note CMS-2567L ATGO21199 YXPSI1 Jf continuation sheet 8 of 23 Ane ee ee ee ee rUKM APPKUVEL) HEALTH CARE FINANCING ADMINISTRATION °2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED B. WING _ __ 105567 07/11/2002 NAME OF PROVIDER OR SUPPLIER. STREET ADDRESS, CITY, STATE, ZIP CODE ‘INGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (x4) D | SUMMARY STATEMENT OF DEFICIENCIES ID j PROVIDER'S PLAN OF CORRECTION (x3) PREFIX {EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG j OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DEFICIENC Dare F 309) Continued From page 8 F 309 contained the following recommendations: 1) A diet 1 order clarification to read No Added Salt, Low Potassium, 2) Verification that the fluid restriction was still needed, and 3) A reduction of the supplement to 3 oz twice daily. These recommendations were not communicated to the physician by the RD until faxed on 6/20/02. The physician responded by asking the following questions which were faxed to the facility on the same date: "Does he have Pedal Edema? Does he have SOB (Shortness of Breath)? Where F/U SMA-7 (the ordered lab work) from 6/07/02?" On 6/25/02, the physician entered a note into the medical record indicating that the resident's weight was now 202 (a gain of 29 pounds since 5/22), that the resident had increased shortness of breath, and pedal edema. His plan was to increase the Demadex to 60 mg. daily for 3 days, then 40 mg. daily after that. He ordered additional labs to be completed in 4 days with the results faxed to his office. The next note by the RD was entered into the record on 7/01/02. The resident's weight was documented in the note to be 202 pounds. The note further documents that the physician did not approve the recommendations of 6/20/02 by the RD. Lab work was completed on 7/01, which showed the BUN to be 50 and the Creatinine to be 2.4. He ordered the labs to be repeated in 2 weeks. On 7/07 the physician ordered Lasix 40 mg. 1 time dose (The resident's weight had been recorded to have increased to 205 on 7/02). On 7/08, the physician entered a note into the record that documented increased weight and swelling of the legs. The weight is recorded by the physician to be 216 pounds. 2 - 3+ edema bilaterally is documented with the diagnosis of End-stage Cardiomyopathy and a CMS-2567L ATGO2NI99 YXPS11 If continuation sheet 9 of 23 nn ee a FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION \(X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BULDING COMPLETED B. WING 405567 . 07/31/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE XINGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (x4 ID | SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY! PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG _ ICROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY, DATE i F 309} Continued From page 9 F309 | plan to increase diuretics. The Demadex was increased to 80 mg. daily and fluids were further restricted to 1000 cc per 24 hours. On 7/03, the RD entered a note into the record stating that she still concurred with her previous recommendations that had been declined by the physician and that she would monitor and follow-up routinely. On the third day of the survey 7/10, the physician responded to a request by the facility that he visits the resident regarding concerns of increased weight and edema. His note documents that the resident is in Severe End-Stage Cardiomyopathy with an ejection factor of 10%, He documents the Pre-Renal Azotemia secondary to decreased cardiac output, He further States that the facility has been keeping him well aware of status. He documents the resident's edema as 1+ arm, 1-2+ sacral, and 2-3 legs with weeping vesicles. The abdomen has 2+ Ascites. His weight has decreased from 216 to 211. The physician states that the edema is secondary to Cardiomyopathy and CHF (Congestive Heart Failure) with no hope of significant improvement, The plan is to increase the Demadex, but prognosis is very poor. The physician clarified the diet order to be 2 Gram Sodium, Low Potassium, 1000 cc/24 hours fluid restriction and increased the Demadex to 80 mg. twice daily. He also ordered a Hospice consult, Resident #15 was observed during the noon meal to receive a Low Potassium diet. He was served a 12 oz glass of water, a 4 oz. glass of apple juice, and was offered a glass of tea by the wait staff. When staff started to salt his food, he stopped the-staff person stating, "I don't want any extra salt." The stuffing served to him was an instant stuffing mix per interview with the Dietary Manager at 11:45 A.M. on 7/10/02. CMS-2567L ATG021199 YXPS11 If continuation sheet 10 of 23 won eres Cae a FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION KX3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BULDING COMPLETED B. WING a 105567 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE “INGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (x4)ID | SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX |(EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY PREFIX (QEACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE i | F 309! Continued From page 10 | F309 | Taste test by the Surveyor revealed a salty product. The resident stated during the noon meal that he was not feeling well because he was all "puffed-up" with fluid. He stated that his leg and hands were so tight that they hurt. The alert resident stated that he knew he should be on a salt-restricted diet, but that the facility continued to serve him salty foods. Observation of the resident's room at 12:30 P.M. on 7/10 revealed, 2, 8 oz. bottles of water (1 of which was half empty) and a 4 oz, cup of water. (20 ounces of water is equal to 600 cc.) On 7/08/02, the fluid restriction had been adjusted by the physician to allow only 1000 cc in a 24 hour period. Current standards of practice for nutritional interventions for Renal Insufficiency as outlined in the 2002 Edition of The Florida Diet Manual specify the following: "Recent studies have suggested that a diet low in protein and phosphorus may slow or prevent the progression of renal disease...Protein restriction is the major component of nutritional management for Chronic Renal Insufficiency. The current recommendation is 0.6 gm per kg. of IBW (Ideal Body Weight)...The usual sodium prescription ranges between 1 to 3 gm per day." The diet manual further specifies: "The nutrition therapy for congestive heart } failure aims to decrease the sodium retention, edema and cachexia that often accompany this disorder." The recommended level of sodium restriction is 2 gm or less for patients with severe heart failure. At no time did the facility's Consultant RD recommend a diet that incorporates these standards of nutritional care. The physician's office was contacted on 7/15/02 for a response to the 2 Gram Na diet order. The spokesperson for the physician stated, "The doctor wants him on a 2 Gram Na diet." CMS-2567L ATGO21199 YXPS11 If continuation sheet 1} of 23 me FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION 2567-L STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA F0K2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED B. WING 105567 ~ 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ’ INGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (x4 | SUMMARY STATEMENT OF DEFICIENCIES D PROVIDER'S PLAN OF CORRECTION 06) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE | [F308] 1 F 309| Continued From page 11 F 309 | S9A-4.1288 Class IT Correction Date: 8/11/02 F 324| 483.25(h)(2) QUALITY OF CARE F 324 | SS=G afailo The facility must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. This Requirement is not met as evidenced by: | Based on observations, interviews of facility staff and family, and record review, the facility failed to provide needed supervision of and assistance with ambulation, failed to provide the needed equipment (rolling walker) for safe ambulation that was identified on the admission RAI (Resident Assessment Instrument) and , failed to timely assess the cause of multiple falls and ‘ appropriately revise interventions for 1 (Resident #1) of 10 active sampled residents who were identified as experiencing falls resulting in multiple injuries to this severely cognitively impaired resident including a fracture of the left distal radius. The findings include: Resident #1 was admitted to the facility on 1/14/02 with diagnoses including Manic Depression and Hypothyroidism. The RAI (Resident Assessment Instrument) completed 1/28/02, identified this resident as being admitted due to decline in cognition and requiring cueing and supervision with ADLs (Activities of Daily Living). “Resident is ambulatory with walker and...wanders without safety awareness." She is coded as being severely cognitively impaired. | The RAI identified unsteady balance. However, the RAI did not identify any devices under Section G5. CMS-2567L ATGO21ES9 1) Resident #1 was r¢ Prope, equipment provided im"? by evaluation Staff inservi supervision of assisted 2) All residents at risi’ “th Proper safety device 3) Unit Manager to ¢’*5 assisted device as ir /screening. 4) DON to monitor Hts of audit. If continuation sheet 12 of 23 YXPS11 on nn nee a de a FORM APPROVED BEALTH CARE FINANCING ADMINISTRATION 2567-L ‘STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED ee =. B. WING 105567 es 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE XINGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (X4)D SUMMARY STATEMENT OF DEFICIENCIES ] ID j PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG ICROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE F 324) Continued From page 12 F324 | "Modes of Locomotion." The RAP (Resident } Assessment Protocol) for falls is as follows: "Res (Resident) has risk for falls based on unsteady gait and predilection to roam in the hallways...Res reminded to call for assist and not ambulate independently without supervision. Falling Star Program, Thera (Therapy) Eval. (Evaluation) of gait and balance and redirection used." The RAI identified the resident to be | independent in transfers while requiring supervision with locomotion. The resultant Care Plan of 2/04/02 identified the concern of “Potential for fall d/t (due to) independent ambulation with decline in cognition." The following 5 approaches were listed on the Care Plan on 2/04/02: "1) Falling star program, 2) Monitor for appropriate footwear, 3) Shower/bath assistance, 4) Cued and reoriented as needed, and 5) PT (Physical Therapy) to screen for gait and balance level." Review of nursing notes dated 2/ 12/02, revealed that the resident was found to have an ecchymotic area of unknown origin to the right post forearm measuring 8 cm. X 5 cm. On 2/14/02, the approach of "apply bed alarm if noted attempts to get OOB (out of bed) was added to the care plan." Nursing notes of 3/06/02, reveal the resident was found sitting on the floor in front of the bathroom. An incident report was completed with a corrective action of having the resident wear flat shoes with low heels. However, this approach was not added to the Care Plan. Nursing notes of 4/27/02, document that the resident's left arm is swollen and discolored. The resident was Teported to voice discomfort when the arm was touched. Ice was applied and an order for an x-ray of the left wrist and left arm was obtained. The results CMS-2567L ATGO2II99 YXPS11 If continuation sheet 13 of 23 TID AAT A Ob i tee ae asus OLD FORM APPROVEL HEALTH CARE FINANCING ADMINISTRATION 2567-1 STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED « B, WING 105567 ees 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE XINGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ] ID | PROVIDER'S PLAN OF CORRECTION + (KS) PREFIX /(EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG \CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} DATE | | F 324) Continued From page 13 F 324 | were negative. An investigation conducted by the ; facility revealed that the resident had lost her balance | while being assisted into bed by her husband, had fallen and struck her left arm against a wastepaper basket. The corrective action plan of the facility was to instruct the husband to call for assistance when assisting his wife. However, the MDS (Minimum Data Set) completed on 4/24/02 as a quarterly assessment specifies the resident to be independent with transfers, No additional approaches were added to the Care Plan as a result of this assessment even though the ‘assessment identifies recent falls. Nursing notes of 5/1 1/02, document a large ecchymotic area (bluish purple color) on right outer gluteal. The note states that the resident ambulates "per self" and is unable to give any information regarding the injury. There was no documentation that further investigation into the cause of the injury was conducted by the facility. No additional approaches were added to the Care Plan, On 5/13/02, an order was obtained for an x-ray of the resident's left wrist due to swelling and pain. The X-ray was negative for fracture, On 5/18/02, the following approach was added to the Care Plan for falls: "Use physical assist at arm and elbow to prevent stumbling. Remind (Resident) not to get out of bed unassisted." The medical record of this resident contains a copy of a fax sent to the attending physician on 5/18/02, which relates that the resident was found on the floor at 4:15 A.M. next to the bed with abrasions on right knee and right side forehead at eyebrow with edema. Nursing notes of the same date confirm that the resident's husband was notified of the fall and of the injuries to the resident's head and knee. The note further CMS-2567L ATGO2L199 YXPS11 If continuation sheet 14 of 23 Te in ee ee ca Gk Pate FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION 2567-L sratemehtr OF DEFICIENCIES (<1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 105567 BING (X3) DATE SURVEY COMPLETED 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SINGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (X4) D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (xs) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY | PREFIX (BACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY ) DATE F 324] Continued From page 14 F 324 identifies an injury to the resident's 4th finger of the left hand, which is described as swollen and purple. The physician was notified and ordered a low bed. The resident was taken by her husband to the emergency room for an x-ray and a CAT scan. The results of both were negative. The resident's husband of 59 years visits twice daily. During interview at noon on 7/ 10/02, the husband, who expressed that it was not necessary to safeguard his identity, stated that his wife had been x-rayed due to injuries on three occasions. He related that he and his daughter who is a physician were concerned about the persistent swelling in his wife's arm and had taken her to an Orthopedic Surgeon for a third x-ray. This third x-ray had confirmed a fracture. The results of this consultation, which had taken place on 6/11/02, were found in the resident's record and stated that the resident had fallen in early May and initial x-rays were read as negative. The consult explains that the resident's husband was concemed due to persistent swelling. The Radiologic Data is as follows: "Plain films of the wrist demonstrate a healed distal radius fracture in near anatomic alignment." The Impression reads: "Clinical and radiographically healed left distal radius fracture." The physician further explained, "I told her and her husband to expect some soft tissue swelling for another month or two.” Interview with the facility's Administrator and Director of Nursing on 7/ 10/02, revealed that neither were aware of the reported fracture. The resident's record confirms that an additional fall happened on 6/10/02. No explanation was given other than the resident was found on the floor. On 6/13/02, an approach of "wheelchair, instructed in use" was added to the Care Plan, At this point, after ———_L__ CMS-2567L, ATGO21199 YXPSI1 if continuation sheet 15 of 23 DEAT B7 Din Cig TR A OILY OER VILE FORM APPROVED HEALTH CARE FINANCING ADMINISTRATION 2567-L STATEMINT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA €X2) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED B, WING a 105567 To 07/1 1/2002 NAME OF PROVIDER, OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE INGS AT LAKE POINT WOODS 7848 BENEVA RD SARASOTA, FL 34238 (x4ID | SUMMARY STATEMENT OF DEFICIENCIES 1D ' PROVIDER'S PLAN OF CORRECTION | (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY, PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | OR LSC IDENTIFYING INFORMATION) TAG (CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE a | | F 324) Continued From page 15 F 324 | multiple falls and injuries, a request was sent to PT | ; (Physical Therapy) for a screen for the use of a walker. | The findings of the screen conducted one week later on 6/17 confirm that the resident Tequires assistance and supervision with cues in all mobility and ADLs secondary to cognitive impairment and is able to ambulate with rolling walker, The PT screen documents that both nursing and nursing assistants were instructed to monitor use and safety. A follow-up was conducted by PT on 6/19 as follows: "Nursing reports pt (patient) doing well with walker, Still requires S (Supervision) with or without walker secondary to decreased cognition. During the first three days of the survey the resident was observed to be ambulating around the hallways of the facility and wandering into resident rooms without benefit of a rolling walker or wheelchair and without supervision or assistance. A wheelchair was noted to be pushed against the wall in the resident's room during these 3 days, No rolling walker was in the resident's room during these observations. During interview of the husband on 7/ 10/02 at noon, the husband stated that he did not know what happened to the walker. He stated that he remained worried about his wife falling and that he let her use his walker (observed to be a 3-wheeled rolling walker) to ambulate when he was visiting his wife at the facility. He stated, “It's my fault; I should have asked about the walker." During interview on 7/1 1/02, the facility's Administrator reported to the Surveyor that the Director of Nursing had stated that she thought the husband was using the resident's walkér. Interview with the Physical Therapy at 9:45 A.M. on 7/\1, confirmed that the husband's 3-wheeled walker CMS-2567L. ATGO21199 YXPSII If continuation sheet 16 of 23 FORM APPROVED Aa QUIN LD HEALTH CARE FINANCING ADMINISTRATION STATEMISNT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: €X2) MULTIPLE CONSTRUCTION A. BUILDING 105567 oo 07/11/2002 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ‘INGS AT LAKE POINT WOODS 7848 BENEVA RD i SARASOTA, FL 34238 (x4) ID SUMMARY STATEMENT OF DEFICIENCES ID PROVIDER'S PLAN OF CORRECTION (xs) PREFIX | (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY| — PREFIX (BACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG of OR LSC IDENTIFYING INFORMATION) TAG |CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY DATE | —. F 324] Continued From page 16 F 324 | Was quite different from the facility's rolling walkers. | Observation of the resident during the morning hours of 7/11/02 revealed that she was in a wheelchair. One of the facility's 2-wheeled rolling walkers was present in the resident's room. 59A-4.1288 Class IT Correction Date: 8/11/02 F 325) 483.25(1)(1) QUALITY OF CARE F325 SS=D Based on a resident's comprehensive assessment, the (2 f } ar facility must ensure that a resident maintains - q acceptable parameters of nutritional status, such as 1) Resident # 14 RD completed comprehensive QU/41702 body weight and protein levels, unless the resident's assessments of identified significant weight changes Jini ‘es sos of resident #14 to assist in ensuring that the clinical condition demonstrates that this is not resident maintains acceptable parameters of possible, nutritional status, This Requirement is not met as evidenced by: 2) RD recatculated the weights for all in-house . . residents from Jan-July for significant weight loss Based on observations, Tecord reviews and staff and completed a comprehensive nutrition interviews, the facility failed to adequately assess, assessment on those residents identified as having evaluate and revise the Care Plan to address the a significant weight toss. Significant weight loss of! (Resident #14) of I 1, from 3) A comprehensive significant weight loss a sample of 20 active residents reviewed for weight assessment will be completed to assist with loss. This is evidenced by: 1) The resident did not -MS-2567L have a comprehensive nutritional assessment after a significant weight loss of 8.44% in one month. 2) There is no evaluation of the Care Plan that addresses the resident's risk for weight loss, and 3) There were no revisions to the resident's Care Plan to prevent further significant weight loss. The findings include: During the review of Resident #14's clinical record it revealed the following diagnoses: Vascular Disease ATG021199 ensuring that a resident maintains acceptable Parameters of nutrition status for those residents identified as having a significant weight loss. Those residents will be identified using weekly and monthly weights. A NAR (Nutrition at Risk) assessment/tracking tool will be initiated, Residents will be monitored through the NAR (uutriton at Risk) process and by using a NAR/QI tracking tool. RD/CDM will monitor process and report to Quarterly QA. YXPSI1 If continuation sheet 17 of 23

Docket for Case No: 03-000172