~ CERTIFIED ARTICLE NUMBER 7106 4575-1294 2050 0880 Io dZa4 0 aan STATE OF FLORIDA v My ows AGENCY FOR HEALTH CARE ADMINISTRATION f> oy ie ty STATE OF FLORIDA, AGENCY FOR HEALTH “sb $e y CARE ADMINISTRATION, “ads (7 Petitioner, ~ “ etiti ‘a 2) . 6 G vs. AHCA NO: 2001074361 ENGLEWOOD HEALTH CARE ASSOCIATES, LLC, Certified Article Number d/b/a ENGLEWOOD HEALTHCARE AND 7106 457S 1294 2050 0880 REHABILITATION CENTER “SENDERS. RECORD ; 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 ENGLEWOOD HEALTH CARE ASSOCIATES, LLC, d/b/a ENGLEWOOD HEALTHCARE AND REHABILITATION CENTER (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1) This is an action to impose an administrative fine in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) pursuant to Sections 400.022(1)(0), 400.022(3), 400.102(1)(a), 400.102(2), 400.121, and 400.23(8), Florida Statutes and Florida Administrative Code Rule 59A- 4.1288. 2) The Respondent was cited for the deficiencies set forth below as a result of an annual survey conducted on or about December 3 - 6, 2001. JURISDICTION 3) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part I, Florida Statutes. 4) Venue lies in Charlotte County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Florida Administrative Code Rule28-106.207. Page 1 of 8 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 PARTIES 5) AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part NH, Florida Statutes and Chapter 59A-4, Florida Administrative Code. 6) Respondent is a skilled nursing facility located at 1111 Drury Lane, Englewood, Florida 34224. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. Its license number is 11440961 effective through 11/30/2003. COUNT I THE FACILITY FAILED TO PREVENT THE DEVELOPMENT OF AN AVOIDABLE IN-HOUSE ACQUIRED PRESSURE SORE AND FAILED TO ENSURE THAT RESIDENTS WHO HAD PRESSURE SORES RECEIVED NECESSARY TREATMENT AND SERVICES TO PROMOTE HEALING, PREVENT INFECTION AND PREVENT NEW SORES FROM DEVELOPING, 400.022, 400.102(1)(a), 400.121, and 400.23(8)(b), FLA. ADMIN. CODE R. 59A-4,1288 (INCORPORATING BY REFERENCE 42 CFR § 483.25) CLASS Il DEFICIENCY 7) AHCA te-alleges and incorporates (1) through (6) as if fully set forth herein. 8) Based on record review, observations and interview with the DON (Director of Nursing) and an RN (Registered Nurse) Coordinator for 3 (Residents #2, #9 and #13) of 17 active residents sampled the facility failed to ensure that Resident #9 did not develop two avoidable pressure sores and that Residents #2 and #13 received necessary treatment and services for residents at risk for developing pressure sores. 9) The findings include: a) Resident #9, on admission to the facility on 2/1/00, was assessed at high risk for pressure sores. The resident was continually assessed (quarterly and on 11/20/01) at high risk for pressure sores. The resident's medical record revealed that the resident had pressure sores since admission to the facility. b) The resident's MDS (Minimum Data Set) revealed that the resident is total care. The MDS further reveals that the resident is totally dependent for bed mobility, transfer and all Activities of Daily Living. The MDS further revealed that the resident had bilateral limitations in all extremities and is incontinent of both bowel and bladder. c) The resident's Plan of Care revealed on 4/10/01, that the resident had a Stage II pressure sore on her coccyx area. On 5/24/01, the Plan of Care revealed, "resolved area, continues at risk related to incontinence, immobility - healed areas." One of the Plan of Care interventions revealed, "to monitor skin per facility protocol check all skin areas while bathing report any areas of concern to nurse." The last time the Plan of Care was updated for at risk for alterations in skin integrity was 9/27/01. d) The resident's nursing summary for the month of October and November 2001, revealed no pressure sores. The resident's bath report completed by a CNA (Certified Nurse Aide) and cosigned by an RN on 12/01/01 revealed no skin concerns. ¢} On 12/3/01 concerns from observations of another resident by surveyor prompted the facility to do skin checks the evening of 12/03/01 on all residents who were at risk for pressure sores. Resident Page 2 of 8 g) h) d k) ) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 #9 was assessed the evening of 12/3/01, revealing an open area on the coccyx. Prior to 12/03/01, there was no documentation in the nurses notes or staging and measurement of a pressure sore or treatment for a pressure sore on the coccyx area. On 12/04/01, the DON stated that all residents in the facility who were at risk for pressure sores were assessed the evening of 12/03/01. On 12/04/01 at 10:05 A.M., the resident was observed with a Hydrocolloid dressing approximately 4 X 3 in size over the coccyx area. A Stage II pressure sore with no dressing in place was observed on the upper right buttocks gluteal fold. Removal of the Hydrocolloid dressing as described by the two nurses, revealed a Stage II pressure sore mid coccyx and several skin tears due to the removal of the dressing. This was verified by two nurses who assisted in the observations. On interview with the DON on 12/4/01, she was unaware of the number of pressure sores observed and was unable to say how long the Hydrocolloid dressing was in place. The DON was made aware that their was no physician order for the Hydrocolloid dressing. Subsequent to the surveyors intervention the following was instituted. The physician was called and the physician progress notes revealed on 12/04/01, "Patient has developed Stage II Decubitus (Pressure Sore) on the buttocks." Physician orders were prescribed for the treatment of the pressure sore as well as blood work. A weekly skin report on 12/4/01 revealed, "6 small superficial open areas, the largest 1 X 1.3 cm on coccyx, newly identified on 12/3/01." An Immediate Plan of Care was updated to address the care and interventions for new pressure sores. In-service training of staff on reporting open and red areas to supervisor, treatment orders and doctors notification. The resident's nurses notes on 12/5/01 revealed, "Late entry, Spoke with floor nurse. Nurse stated that the resident had "red" area noted to coccyx area and floor nurse applied Duoderm for protective treatment." The laboratory results dated 12/05/01, revealed an albumin of 2.9 Low - reference 3.2 - 4.8 G/dL. On interview with the DON on 12/5/01 at 11:45 A.M. she stated, "We have not had a wound care nurse for over a month on the south wing unit. The nurse coordinator for the unit is the designated wound care nurse.” She further stated, "The pressure sores were unavoidable due to old scar tissue from previous pressure sores." 10) The findings also include: a) b) c) Review of Resident #2's clinical record revealed that the resident had been sent to the hospital from the facility on 11/16/01. Review of the hospital History and Physical completed 11/17/01, revealed that the resident had been admitted with bilateral pneumonia, probable sepsis and fluid overload. The resident returned to the facility on 11/24/01. Review of the Patient Transfer and Continuity of Care form completed on 11/24/01, listed the resident's diagnoses as Pneumonia, Congestive Heart Failure, Dementia and Sacral Decubitus. The decubitus was described on the form as a 1-centimeter by 1 centimeter, Stage I] wound on the coccyx with a Telfa dressing and "Two small blisters on back." ""Telfa applied." The medication and treatment orders on the form stated, "dressing to sacral decub." Review of the laboratory data dated 11/16/01, revealed that the resident had a low albumin level of 1.9 g/dl (reference range 3.4-5.0 g/dl); indicative of depleted protein stores, which can effect wound healing. Review of the readmission Clinical Assessment revealed that it was blank and had not been completed by the nurse. Review of the nurses notes dated 11/24/01 at 4:00 P.M. revealed, "Skin examination reveals intact skin...” with no documentation of the resident's dressings or wounds. Review of the weekly skin assessments revealed that there was no documentation that a skin assessment had been completed since 10/30/01. Page 3 of 8 d) @) 8) h) a) k) CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 Interview with the Medical Record Director on 12/6/01 at 12:45 P.M., revealed that she could not locate any skin assessments for this resident for 11/01 and 12/01. Review of the Minimum Data Set (MDS) revealed that there was no MDS completed on readmission as of 12/03/01. Review of the Care Plan revealed it had not been updated since 5/24/01. The resident's record did not contain an Immediate Plan of Care, which addressed the resident's pressure sores. Review of the physician readmission note dated 11/27/01, indicated that the resident had pressure sores on her sacrum. Review of the 11/0] and 12/01, physician's orders revealed no order for treatment of the pressure sores or clarifications regarding the dressing on the wounds other than the statement that their was a dressing on the sacral decubiti on the hospital transfer form. Review of the Treatment Records dated 11/01 and 12/01, revealed no documentation of treatments being done by the nursing staff for the resident's pressure sores. The 7 A.M. to 3 P.M. shift nurse confirmed this. Review of the dietary progress notes dated 11/26/01, revealed the Certified Dietary Manager (CDM) had documented that the resident was receiving a tube feeding of Jevity at 70 cc per hour with water flushes. A low hemoglobin and hematocrit were noted but the resident's depressed albumin levels were not addressed. The CDM noted the Stage II pressure sore on the coccyx. The plan was "Will continue with current POC (plan of care)." There was no documentation of the adequacy of the tube feeding or assessment of the resident's increased nutritional needs with the pressure sores, low albumin level and recent infection. There was no documentation that the resident was referred to the Registered Dietitian (RD) for reassessment. Interview with the CDM on 12/4/01 at 1:15 P.M., revealed that he had missed the resident’s low albumin and had added the resident to the RD's sheet for reassessment at her next visit. He confirmed that he did not call the RD to inform her of the resident's change in condition and need for reassessment. Interview with the RD on 12/4/01 at 1:30 P.M., revealed that she had not consulted at the facility the last week in November and had reassessed the resident on 12/3/01. Observation of the resident by the nurse surveyor with the evening staff nurse on 12/03/01 at 3:45 P.M., revealed that the resident had a Telfa dressing on her coccyx dated 11/24/01 and a dressing below this dated 11/27/01. The lower dressing was moist, dirty and soiled with feces, The staff nurse removed the upper dressing, tearing the skin as the dressing was removed. The skin under the lower dressing was moist but healed. Interview with the evening staff nurse on 12/03/01 at 4:05 P.M., revealed that he was not aware that the resident had these dressing on or that she had a skin problem. He stated that he would only know this if it were documented on the treatment record. He confirmed that the upper dressing dated 11/24 was the dressing the resident was admitted with from the hospital and had not been changed in the last 10 days. He stated that the facility did not carry this type of dressing so he knew that it was not applied at the facility. He stated that the lower dressing dated 11/27 was "probably" applied by the facility staff as a preventative measure. When questioned why there were no orders for the dressing, the nurse replied that they did not need to get orders when the dressings are used as a preventative measure. He stated that dressings should be changed in 3 to 7 days and he could not believe that the nurse who readmitted the resident did not assess the resident for the pressure sores or obtain treatment orders. Interview with the Director of Nursing (DON) on 12/3/01 at 4:20 P.M., revealed that she was not aware that the resident had the pressure sores and dressings. She stated that she was aware that there were problems in the facility with wound assessment and she had hired a wound care nurse who would start next week. She stated that she would have the evening nurses completed a skin assessment on all residents on that unit. Page 4 of 8 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 m) Further interview with the DON on 12/4/01 at 11:30 A.M., revealed that she had conducted an in- service for the nursing staff regarding obtaining orders for all pressure sore treatments and dressings. She further stated that the physician had been contacted regarding treatment orders for Resident #2 and the MDS Coordinator had completed the MDS today on 12/4/01. n) Review of the MDS, not signed and dated as complete on 12/4/01, indicated that the resident had no pressure sores documented in the last 7 days in the Skin Condition section. 0) Subsequent to surveyor intervention, the evening nurse completed a clinical assessment of the resident at 5 P.M. on 12/3/01 and documented a Stage II blister above the coccyx that measured 1} cm X 2 cm and a Stage I area on coccyx that measured 6 cm X 7 cm. The nurse documented that an Ultec dressing was applied on the coccyx to protect and triple antibiotic and Coverderm dressing on the Stage II pressure sore. p) Review of the physician's telephone orders dated 12/3/01, revealed that the facility obtained orders from the physician for these treatments at 5:00 P.M. q) Review of the RD reassessment revealed that she recommended that the resident be changed to a higher protein formula due to the "severely depleted" albumin level and presence of decubitus ulcers and add vitamin and mineral supplementation. The Care Plan was revised on 12/4/01 to reflect the resident pressure sores. The December 01, Treatment Record was revised on 12/4/01 to reflect the new treatment orders. 11) The findings also include: a) Resident #13 was assessed for at risk for pressure sores. The resident has a history of having pressure sores, b) The resident's MDS revealed that the resident is total care. The MDS also reveals that the resident is totally dependent for bed mobility, transfer and all of her Activities of Daily Living. The MDS further reveals that the resident is incontinent of bowel and bladder. c) The resident medical record bath report (skin assessment) completed by a CNA and cosigned by an RN revealed on 10/20/01, redden area on right and left buttocks with an open area in the perineal area. The resident's medical record revealed no other documentation of the pressure areas or open area, follow up, care, treatment or interventions. d) On interview with the Nurse Coordinator from the North Wing she confirmed that the South Wing has not had a wound treatment nurse to document the observations or follow up on the observation made by the CNA during the resident's bath on 10/20/01. "Apparently no one else knew of the observation made by the CNA." e) On observations on 12/06/01, the resident was found to be incontinent of bowel and bladder there was no open area noted. 12) Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent, based upon a comprehensive assessment of a resident, to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable. That rule incorporates by reference 42 CFR § 483.25(c)(1). 13) Based upon the forgoing, the Respondent violated Florida Administrative Code Rule 59A-4.1288, which required the Respondent to ensure that residents who had pressure sores received necessary Page 5 of 8 CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 treatment and services to promote healing, prevent infection and prevent new sores from developing. That rule incorporates by reference 42 CFR § 483.25(c)(2). 14) The foregoing also constitutes a violation of § 400.022, Fla. Stat., which requires the Respondent to ensure the residents’ right to receive adequate and appropriate health care and protective and support services, 15) The foregoing also constitutes an intentional or negligent act materially affecting the health or safety of residents of the facility as defined by § 400.102 (1)(a), Fla. Stat. and is subject to a fine under § 400.121 Fla. Stat. 16) The foregoing constitutes a Class II deficiency as defined by § 400.23(8)(b) Fla. Stat. as follows: A class II deficiency is a deficiency that the agency determines has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 17) The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) is authorized under § 400.23(8), Fla. Stat. CLAIM FOR RELIEF 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 TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) for the violation cited in Count I against the Respondent under §§ 400.022, 400.102(1)(a), 400.121(1), and 400.23(8)(b), Fla. Stat. and Fla. Admin. Code R. 59A-4.1288 (incorporating by reference 42 CFR § 483.13). Page 6 of 8 ~ CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 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, Soomne Bale Joanna Daniels FL Bar #0118321 Assistant General Counsel Agency for Health Care Administration 2727 Mahan Dr., MS #3 Tallahassee, FL 32301 (850) 922-5873 Fax (850) 413-9313 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Administrator, Englewood Healthcare and Rehabilitation Center, 1111 Drury Lane, Englewood Florida 34224 Return Receipt No. 7106 4575 1294 2050 0880, on December 30, 2002. Joanna Daniels Assistant General Counsel Page 7 of 8 ~ CERTIFIED ARTICLE NUMBER 7106 4575 1294 2050 0880 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) (Interoffice Mail JD/ghm Page 8 of 8

Docket for Case No: 03-000191