STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (3 APR 28 PH h 725 STATE OF FLORIDA AGENCY FOR HEALTH WiShou a CARE ADMINISTRATION, ADMINIS T Ra rj HEAKinES Petitioner, 0-150 | vs. AHCA NO: 2003001251 AGE INSTITUTE OF FLORIDA, INC., d/b/a BARTOW CENTER, 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 AGE INSTITUTE OF FLORIDA, INC., d/b/a BARTOW CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of Forty One Thousand Dollars ($41,000), pursuant to Sections 400.23(8) (a) and 400.102(1) (d) Florida Statutes 2. The Respondent was cited for the deficiency during a complaint survey conducted on or about February 11, 2003. JURISDICTION 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4, Venue lies in Polk County, Division of Administrative Hearings, pursuant to 120.57 Florida Statutes, and Chapter 28- 106.207, F.A.C. 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, F.A.C. 6. Respondent is a nursing home located at 2055 Fast Georgia Street, Bartow, Florida 33830. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, F.A.C. COUNT I RESPONDENT FAILED TO MEET PROFESSIONAL STANDARDS OF QUALITY BY NOT FOLLOWING FACILITY POLICY AND PROCEDURE VIOLATING Fl. Admin Code R. 59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 483.20 (d) (3) CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. A complaint survey was conducted on February 11, 2003. 9. On that date, based on observation, interviews and record review, the facility failed to meet professional standards of quality by not following facility policy and procedure for implementing cardiopulmonary resuscitation (CPR) in emergency situations by qualified staff for one of one residents who required immediate resuscitative interventions 2 (#5). The resident did not receive resuscitation resulting in findings of Immediate Jeopardy. 10. A Class I deficiency was cited against Respondent based on the findings below: 1. Resident #5 was admitted to the facility on 7/9/02 at 4:15 p.m. with multiple medical conditions. Record review of the nurse's progress notes, dated 7/10/02 at 6:00 a.m., reflected that the resident was "alert" and given a routine nebulizer (breathing) treatment per physician's order. The resident was also suctioned of "white mucous" secretions at that time by the licensed practical nurse (LPN) . 2. At 6:45 a.m. on 7/10/02 the nurse's progress notes documents that the LPN was called into the resident's room by the certified nurse's assistant (CNA) and was "notified" of the resident's "condition." The LPN checked for pulses and finding none, called another LPN "for verification." The LPN called the resident's physician at 7:00 a.m. to "notify" him/her of resident's "condition." Family members were notified by the LPN at 7:15 a.m. and 8:00 a.m. There is no documentation in the medical record that CPR was initiated or that emergency medical service was called for assistance. There is no documentation in the medical record that the resident had a Do Not Resuscitate (DNR) order, and therefore, according to facility policy, CPR was to be initiated. Regulations of Professionals and Occupations, Chapter 464, Part I, Nurse Practice Act, states the practical nurse performs "selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others" and further that "the practical nurse shall be responsible and accountable for making decisions that are based upon educational preparation and experience in nursing." 3. In a late entry made in the nurse's progress notes dated 7/10/02 at 11:00 p.m., another LPN stated that at approximately 6:40 a.m. on 7/10/02 she was called into the resident's (#5) room by the LPN who stated the resident "was dead." This LPN documents that she "checked pulses, respirations and heart sounds resulting in zero activity." This LPN further documents that the resident's hands were "cool and blue" and the feet were "warm." This LPN asked the LPN caring for the resident if the resident was a "DNR" and the LPN responded that she "knew nothing about the resident" and proceeded to leave the room and go to the nurse's station. This LPN remained in the room with the CNA and documents she performed a "sternal rub” on the resident, resulting in "no response." 4. During the initial tour of the facility on 2/11/03 ac ll:uC a.m. it was observed that there were red or green circle-shaped stickers on each resident's door nameplate. These stickers were also observed on resident armbands and on the spine of resident charts. An interview with an LPN on 2/11/03 at 12:45 p.m. revealed that these red and green stickers identified if a resident was a full code (green=go) or a DNR (red=stop) . 5. An interview with the Director of Nursing (DON) on 2/11/03 at 1:15 p.m. revealed that the LPN never initiated CPR and it was the facility's policy that CPR should have been attempted. She further stated that as a result of this resident not receiving CPR, mandatory in- services were given to nursing staff regarding CPR policy and documentation on 7/10/02, 7/11/02 and 7/12/02. The DON also indicated that the facility had written a pian to improve performance in the areas of determining code status on a new admission, assuring CPR is initiated following cardiac/respiratory arrest per facility policy and that nursing documentation supports any decision not to initiate CPR. 6. Review of the facility's policy and procedure for CPR, effective April 2000, states that "unless a decision not to initiate CPR has previously been made by the resident, CPR will be initiated for any resident, visitor or staff member who experiences a cardiopulmonary arrest while in the center. If a decision (code status) has not been established and documented, CPR will be initiated." 7. Review of the LPN's personnel record revealed that the LPN held certification in basic life support (CPR) for healthcare providers in accordance with the curriculum of the American Heart Association, and was suspended on 7/10/02 pending the facility's further investigation of the incident per the Disciplinary Action form dated 7/10/02. The LPN responded on this document that as a "new" LPN she felt she had not been "properly oriented" and "taken on the floor without any knowledge.” 11. The above actions or inactions of the facility constitute a violation of 59A-4.1288 incorporating by reference 42 CFR 483.20(d) (3) (i) requires that the services provided or arranged by the facility must meet professional standards of quality. Additionally since this deficiency was one of serious noncompliance that included immediate jeopardy and was discovered between surveys the facility was also cited under Tag 698 for past noncompliance. 12. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Fifteen Thousand Dollars ($15,000) is authorized pursuant to Sections 400.102(1) (a,d), 406.121(1), and 400.23(8) (a), Florida Statutes COUNT II RESPONDENT FAILED TO EMPLOY A SYSTEM WHICH ENSURED THE PROMPT IDENTIFICATION OF A NEWLY ADMITTED RESIDENT AND WHETHER OR NOT THAT RESIDENT HAD FORMULATED AN ADVANCE DIRECTIVE, FOR PURPOSES OF IMPLEMENTATION OF SAME VIOLATING Fl. Admin Code R. 59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 483.10(B) (5) - (10) CLASS I DEFICIENCY 13. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 14. A complaint survey was conducted on February 11, 2003. 15. On that date, based on observation, interviews and record review, the facility did not employ a system which ensured the prompt identification of a newly admitted resident and whether or not that resident had formulated advance directives, for purposes of implementation of same. There was a facility-wide system in place to identify established residents with advance directives. Staff was not knowledgeable on when an advance directive was applicable for a newly admitted resident. Lack of knowledge regarding advance directives and failure on the part of the facility to promptly identify the wishes of newly admitted residents, placed one of one residents reviewed 7 (#5) at risk for not receiving emergency lifesaving treatment and resulted in findings of Immediate Jeopardy. 16. A Class I deficiency was cited against Respondent based on the findings below: 1. Resident #5 was admitted to the facility on 7/9/02 at 4:15 p.m. with multiple medical conditions. Review of the resident's medical record revealed that there was no documentation that the resident had a Do Not Resuscitate (DNR) order, nor any documentation of advance directives. 2. At 6:45 a.m. on 7/10/02 the nurse's progress notes documents that the LPN was called into the resident's room by the certified nurse's assistant (CNA) and was "notified" of the resident's "condition." The LPN checked for pulses and finding none, called another LPN "for verification." The LPN called the resident's physician at 7:00 a.m. to "notify" him/her of resident's "condition." Family members were notified by the LPN at 7:15 a.m. and 8:00 a.m. There was no documentation in the medical record that CPR was initiated or that emergency medical services was called for assistance, consistent with the facility's April, 2000 "Cardiopulmonary Resuscitation (CPR) - Basic Life Support (BLS)" policy. In a late entry made into the nurse's progress notes, dated 7/10/02 at 11:00 p.m., another LPN stated that at approximately 6:40 a.m. on 7/10/02 she was called into the resident's (#5) xoom by the LPN who stated the resident "was dead." This LPN documents that she "checked pulses, respirations and heart scunds resulting in zero activity." This LPN further documents that the resident's hands were "cool and blue" and the feet were "warm." This LPN asked the LPN caring for the resident if the resident was a "DNR" and the LPN responded that she "knew nothing about the resident" and proceeded to leave the room and go to the nurse's station. This LPN remained in the room with the CNA and documents she performed a "sternal rub" on the resident, resulting in "no response." 3. During the initial tour of the facility on 2/11/03 at 11:00 a.m. it was observed that there were red or green circle-shaped stickers on each resident's door nameplate. These stickers were also observed on resident armbands and on the spine of resident charts. An interview with an LPN on 2/11/03 at 12:45 p.m. revealed that these red and green stickers identified if a resident was a full code (green=go) or a DNR (red=stop) . 4. An interview with the Director of Nursing (DON) on 2/11/03 at 1:15 p.m. revealed that the LPN never initiated CPR and it was the facility's policy that CPR should have been attempted. The DON did not know why the LPN failed to provide CPR to Resident #5. Review of the facility's policy and procedure for CPR, effective April 2000, states that "unless a decision not to initiate CPR has previously been made by the resident, CPR will be initiated for any resident, visitor or staff member who experiences a cardiopulmonary arrest while in the center. If a decision (code status) has not been established and documented, CPR will be initiated." 5. Review of the LPN's personnel record revealed that the LPN held certification in basic life support (CPR) for healthcare providers in accordance with the curriculum of the American Heart Association, and was suspended on 7/10/02 pending the facility's further investigation of the incident per the Disciplinary Action form dated 7/10/02. The LPN responded on this document that as a "new" LPN she felt she had not been "properly oriented" and "taken on the floor without any knowledge." 6. In an interview on 2/11/03 at 1:15 p.m. the DON stated that as a result of this resident not receiving CPR, mandatory in-services were given to nursing staff regarding CPR policy and documentation on 7/10/02, 7/11/02 and 7/12/02. The DON also indicated that the facility had written a plan to improve performance in the areas of 10 determining code status on a new admission, assuring CPR is initiated following cardiac/respiratory arrest per facility policy and that nursing documentation supports any decision not to initiate CPR. 17. The above actions or inactions of the facility constitute a viclation of 59A-4.1288 incorporating by reference 42 CFR 483.10(B) (5)-(10) which requires: (S) The facility must inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the items and services that are included in nursing facility services under the State plan and for which the resident may not be charged, and the amount of charges for those services; and to inform each resident when changes are made to the items and services specified in paragraphs (5) (i) (A) and (B) of this section. (6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. (7) The facility must furnish a written description of legal rights which includes a description of the manner of protecting personal funds, under paragraph (c) of this section. 11 A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment under section 1924(c) which determines the extent of a couple's non-exempt rescurces at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medicaid eligibility levels. (8) The facility must comply with the requirements specified in subpart I of part 489 of this chapter relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. (9) The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his or her care. (10) The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for 12 and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Additionally, since this deficiency was one of serious noncompliance that included immediate jeopardy and had demonstrated past non-compliance on July 10, 2002, the facility was also cited under Tag 698 for past noncompliance. 18. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Ten Thousand Dollars ($10,000) is authorized pursuant to Sections 400.102(1) (a,d), 400.121(1), and 400.23(8) (a), Florida Statutes COUNT III RESPONDENT FAILED TO PROVIDE NEEDED SERVICES FOR A RESIDENT BY NOT IMPLEMENTING FACILITY PROCEDURES VIOLATING Fl. Admin Code R. 59A-4.1288 INCORPORATING BY REFERENCE 42 CFR 483.13 (c) CLASS I DEFICIENCY 19. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 20. A complaint survey was conducted on February 11, 2003. 21. On that date, based on interviews and record review the facility did not provide needed services for a resident by not implementing facility procedures for one of one residents (#5) who required immediate resuscitative interventions by staff who are certified in cardiopulmonary resuscitation (CPR), and which resulted in findings of Immediate Jeopardy. 13 22. A Class I deficiency was cited against Respondent based on the findings below: 1. Resident #5 was admitted to the facility on 7/9/02 at 4:15 p.m. with multiple medical conditions. Record review of the nurse's progress notes dated 7/10/02 at 6:00 a.m. notes that the resident was "alert" and given a routine nebulizer (breathing) treatment per physicians order. The resident was also suctioned of "white mucous" secretions at that time by the licensed practical nurse (LPN) . 2. At 6:45 a.m. on 7/10/02 the nurse's progress notes documents that the LPN was called into the resident's room by the certified nurse's assistant (CNA) and was "notified" of the resident's "condition." The LPN checked for pulses and finding none, called another LPN "for verification." The LPN called the resident's physician at 7:00 a.m. to "notify" him/her of resident's "condition." Family members were notified by the LPN at 7:15 a.m. and 8:00 a.m. There was no documentation in the medical record that CPR was initiated or that emergency medical services was called for assistance, in keeping with the facility's April, 2000 policy and procedure entitled, "Cardiopulmonary Resuscitation (CPR) - Basic Life Support (BLS)." There is no documentation in the medical record that the resident 14 had a Do Not Resuscitate (DNR) order, and therefore, according to facility policy, CPR was to be initiated. In a late entry made in the nurse's progress notes, dated 7/10/02 at 11:00 p.m., another LPN stated that at approximately 6:40 a.m. on 7/10/02 she was called into the resident's (#5) room by the LPN who stated the resident "was dead." This LPN documents that she "checked pulses, respirations and heart sounds resulting in zero activity." This LPN further documents that the resident's hands were "cool and blue" and the feet were "warm." This LPN asked the LPN caring for the resident if the resident was a "DNR" and the LPN responded that she "knew nothing about the resident" and proceeded to leave the room and go to the nurse's station. This LPN remained in the room with the CNA and documents she performed a "sternal rub" on the resident, resulting in "no response." 3. An interview with the DON on 2/11/03 at 1:15 p.m. revealed that the LPN never initiated CPR and it was the facility's policy that CPR should have been attempted. The DON did not know why the LPN failed to provide CPR to Resident #5. Review of the facility's policy and procedure for CPR, effective April 2000, states that "unless a decision not to initiate CPR has previously been made by the resident, CPR will be initiated for any resident, visitor or staff member who experiences a cardiopulmonary arrest while in the center. If a decision (code status) has not been established and documented, CPR will be initiated." 4, The DON further stated on 2/11/03 at 1:15 p.m., that as a result of this resident not receiving CPR, mandatory in-services were given to nursing staff regarding CPR policy and documentation on 7/10/02, 7/11/02 and 7/12/02. The DON also indicated that the facility had written a plan to improve performance in the areas of determining code status on a new admission, assuring CPR is initiated following cardiac/respiratory arrest per facility policy and that nursing documentation supports any decision not to initiate CPR. 23. The above actions or inactions of the facility constitute a violation of 59A-4.1288 incorporating by reference 42 CFR 483.13 (c) (3) (1) (i) which requires that the facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Additionally since this deficiency was one of serious noncompliance that included immediate jeopardy and was discovered between surveys the facility was also cited under Tag 698 for past noncompliance. 16 24. The above referenced violation constitutes the grounds for the imposed Class I deficiency and for which a fine of Ten Thousand Dollars ($10,000) is authorized pursuant to Sections 400.102(1) (a,d), 400.121(1), and 400.23(8) (a), Florida Statutes ADDITIONAL FEE UNDER §400.19(3), FLORIDA STATUTES 25. The Respondent has been cited for three Class I deficiencies therefore is subject to a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes. 26. Notice was provided in writing to the Respondent of each of the above violation(s) and the time frame for correction. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Counts I, II and III; B. Recommend that the administrative fine of Forty One Thousand Dollars ($41,000) be upheld; and c. Assess costs related to the investigation and prosecution of this case pursuant to § 400.121 (10) Fl. Stat. (2002) D All other general and equitable relief allowed by law. The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). All requests for hearing shall be made to the attention of Eileen O'Hara Garcia, Esquire, AHCA Senior Attorney, Agency for Health Care Administration, 525 Mirror Lake Dr. N., St. Petersburg, Florida, 33701. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. lli}y submitted, Eileen/Garcia, Esquire AHCA Senior Attorney Fla. Bar No. 504149 525 Mirror Lake Drive North, St. Petersburg, Florida 33701 (727) 552-1439 (Office) (727) 552-1440 (Fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true copy hereof was sent by U.S. Mail, to Senior Health Management LLC, Registered Agent for Bartow Center, 100 Second Avenue South, Suite 9015S, St. Petersburg, Florida 33701 and by U.S. Certified Mail, Return Receipt No.7002 2030 U007 8499 6645 to Administrator, Bartow Center, 2055 East Georgia Street, Bartow, Florida 33830, on apes HG 2003. O’Hara Garcia, Esq. Copies furnished to: Senior Health Management LLC Registered Agent for Bartow Center 100 Second Avenue South Suite 901 S$ St. Petersburg, Florida 33701 (U.S. Mail) Administrator Bartow Center 2055 East Georgia Street Bartow, Florida 33830 (U.S. Certified Mail) Eileen O'Hara Garcia AHCA - Senior Attorney 525 Mirror Lake Drive Suite 330D St. Petersburg, Fl 33701 (Interof fice) 19

Docket for Case No: 03-001501