STATE OF FLORIDA ly AGENCY FOR HEALTH CARE ADMINISTRATION Ke. AGENCY FOR HEALTH CARE ADMINISTRATION, ” nog Petitioner, . : OF 156% vs. AHCA NO. 2002045372 EVANS HEALTH CARE ASSOCIATES, LLC d/b/a EVANS HEALTH CARE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against EVANS HEALTH CARE ASSOCIATES, LLC d/b/a EVANS HEALTH CARE (“Evans Health Care”) pursuant to Sections 120.569 and 120.57, Florida Statutes (2001), and alleges: NATURE OF THE ACTION 1. This is an action: (a) to impose a $7,500.00 civil penalty against Evans Health Care pursuant to Sections 400.102(1) (d) and 400.23(8) (b), Florida Statutes (2001), based on three (3) “isolated” class II deficiencies cited against the facility at a survey on or about June 17-20, 2002; and (b) to assess costs related to the investigation and prosecution of the case pursuant to Section 400.121(10), Florida Statutes (2001). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 3. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes (2001). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2001). PARTIES 5. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable Florida laws and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 6. Evans Health Care Associates, LLC, doing business as Evans Health Care, is a Florida limited liability corporation with a principal address of 400 Perimeter Center Terrace, Suite 650, Atlanta, Georgia 30346. 7. Evans Health Care is a 120-bed skilled nursing facility located at 3735 Evans Avenue, Fort Myers, Florida 33901, having been issued license number SNF130470992 by AHCA, 8. Evans Health Care is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. COUNT I EVANS HEALTH CARE FAILED TO ENSURE THAT EACH RESIDENT RECEIVED, AND EVANS HEALTH CARE FAILED TO PROVIDE, THE NECESSARY CARE AND PROPER SERVICES TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING, IN ACCORDANCE WITH THE COMPEREHENSIVE ASSESSMENT AND PLAN OF CARE. 42 CFR § 483.25 (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) CLASS II DEFICIENCY ISOLATED 9. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 10. On or about June 17-20, 2002 AHCA conducted a survey at Evans Health Care. An isolated class II deficiency was cited against Evans Health Care based on the findings below involving resident #4 and resident #6. RESIDENT #4 Resident #4 was admitted to Evans Health Care on or about April 12, 2002 with diagnoses of debility secondary to hospitalization, lumbago, chronic back pain, urinary tract infection and osteoporosis. At the time of admission, Resident #4 was triggered as a fall risk. Resident #4’s pain control was fair at admission and she was prescribed the following medications: Zoloft (anti-depressant) 50 milligrams (“mg.”) by mouth every day; Vioxx (analgesic) 50 mg. by mouth every day, and OxyContin (narcotic analgesic) 30 mg. by mouth every twelve (12) hours. The day after admission, on or about April 13, 2002, Resident #4 "fed herself a regular, full diet” and her weight was 99.6 pounds. Over the next few weeks, Resident #4 continued with Zoloft 50 mg. by mouth every day, OxyContin 20 mg. by mouth every twelve (12) hours, Celebrex 200 mg. one (1) by mouth every day, Ativan (anti- anxiety) 0.5 mg. by mouth every six (6) hours, Vicodin ES (analgesic) one (1) tablet every four (4) hours, and Duragesic (analgesic) 25 meg. patch to be = applied every three (3) days. Resident #4 also received Senokot S (a laxative), two (2) tablets, due to constipation. There was no documentation in the medical record showing that Evans Health Care performed pain management or evaluated Resident #4’s responses to all of the pain medications she was receiving. According to the nurses' notes and controlled drug record, Resident #4 complained of unrelieved pain almost daily, twenty-nine (29) out of thirty-six (36) days, and told caregivers she was unable to eat due to pain. Evans Health Care Changed Resident #4’s diet to a high calorie, full liquid diet. In one (1) month, Resident #4’s weight dropped from about 99.6 pounds to about 88.8 pounds, indicating a significant weight loss of approximately 10.84%. Evans Health Care failed to care plan or care plan adequately for the prevention of falls despite Resident #4’s risk for falls. On admission, Resident #4 triggered as a risk for falls. Also, Resident #4 was assessed as needing assistance with all activities of daily living (“ADLs”). Resident #4 fell on or about June 14, 2002. Evans Health Care failed to send Resident #4 immediately to the hospital for evaluation. Three (3) days later, on June 17, 2002, Evans Health Care transferred Resident #4 to the hospital for evaluation after she complained of severe pain. An X-ray revealed a fractured hip. The AHCA surveyor interviewed the staff nurse, Director of Nursing Services, Care Plan Coordinator and Nurse Consultant. They provided no explanation regarding the lack of assessment and care planning by Evans Health Care that resulted in Resident #4 not reaching or maintaining her highest practical, physical and mental well-being. RESIDENT #6 Resident #6 was admitted to Evans Health Care on or about June 7, 2001. Resident #6 had been identified as a fall risk on or about February 13, 2002. Since that time, Resident #6 experienced multiple falls and fractured his patella. As of the day of the survey, Resident #6 was still experiencing falls. Resident #6 had been on Tylox, one (1) every six (6) hours, since March 22, 2002 without any assessment of pain or pain relief. The AHCA surveyor interviewed Resident #6’s Unit Manager, Care Plan Coordinator, Director of Nursing Services, and Nurse Consultant. None of the providers were able to provide the surveyor with information on the lack of pain management and the lack of interventions to prevent falls. vill. Based on all of the foregoing, Evans Health Care violated 42 CFR § 483.25 via Rule 59A-4.1288, Florida Administrative Code (2001), by failing to ensure that each resident received 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. 12. Pursuant to Section 400.23(8) (b), Florida Statutes, (2001) the foregoing is a class If deficiency because it compromised each resident’s ability to maintain or reach his or her highest practicable Physical, mental, or psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 13. Pursuant to Section 400.23(8), Florida Statutes (2001), the foregoing is an “isolated” class II deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or ina very limited number of locations. 14. Pursuant to Section 400.23(8) (b), Florida Statutes, an isolated class II deficiency warrants a fine of $2,500.00. COUNT II EVANS HEALTH CARE FAILED TO ENSURE THAT EACH RESIDENT RECEIVED ADEQUATE SUPERVISION OR ASSISTANCE DEVICES TO PREVENT ACCIDENTS. 42 CFR § 483.25 (h) (2) (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) CLASS II DEFICIENCY ISOLATED 15. AHCA re-alleges and incorporates by reference Paragraphs one (1) through eight (8) above as if fully set forth herein. 16. On or about June 17-20, 2002 AHCA conducted a survey at Evans Health Care. An isolated class II deficiency was cited against Evans Health Care based on the findings below involving Resident #12 and Resident#15: RESIDENT #12 A review of Resident #12's clinical record revealed an admission date of August 17, 2001. Resident #12’s diagnoses included Alzheimer's Disease, Anxiety State and Intracranial Hemorrhage. A review of the hospital final summary report dated July 25, 2001, revealed discharge diagnoses of, among others, Multiple Infarction Dementia and Subcortical Infarction with Left Hemiparesis (weakness). The clinical record further revealed that the resident was disoriented to time and place, required assistance with transfers and ambulation in his room and required supervision for bed mobility. On or about June 17, 2002 at 9:25 a.m., an AHCA surveyor observed Resident #12 in his room in bed asleep. He had an abduction pillow between his legs. On or about June 17, 2002 an AHCA surveyor observed Resident #12 from 10:40 a.m. through 11:25 a.m. in the secured unit day room. The surveyor observed the resident sitting in a high back wheelchair with a lap tray. He was calm and often had his eyes closed. At 12:45 P.M., the resident was set-up for meal and was fed by a staff member. Resident #12’s care plan dated September 4, 2001 under “problem/strengths” revealed "Falls: Res (resident) at risk for falls due to Alzheimer's Disease, Dementia, unsteady gait and no safety awareness." The care plan goal stated, "Res will have no injuries from falls." The care plan interventions included the following: (a) lap tray; (b) observe for any sliding or any attempts to remove the tray; and (c) when restless and anxious, get him out of chair and ambulate if he will. A further review of the care plan revealed that the resident fell and injured the back of his head on September 21, 2001. The following interventions were added to the care plan: "Resident will stand, remind him to sit down; Anti-tippers on chair." Resident #12 was admitted to the hospital on January 2, 2002 due to inability to bear weight on his left leg. A review of the left hip x-ray performed on January 2, 2002 revealed, "Impression: Left pelvic fracture involving the acetabulum (where the ball-shaped head of the thigh bone articulates)." The X-ray also stated that the left superior and inferior ramus are fractured. The reason for this procedure was "fall/hip pain.” Resident #12 was discharged from the hospital and readmitted to the facility on or about January 5, 2002. A Review of the care plan developed on January 5, 2002 revealed, "Fx (fracture) of left hip - bleeding to left side of head - on bed rest x 6 wks (weeks). OOB (out of bed) for meals only. Added to the current interventions in the care plan developed on August 17, 2001, ‘to address the risk for falls was, "two side rails as enablers" to his bed. The physician ordered bed rest and NWB (non-weight bearing) until his next appointment. A review of the nurse's notes dated January 14, 2002, nine (9) days after his readmission from the hospital, revealed the resident was found on the floor in his room. The nurse's notes stated, "Resident was found with his legs crossed over lying on his back, his side rails were up on both side of his bed. It appears that he scooted to the foot of the bed and fell. Resident c/o (complaining of) pain at the R (right) side." The resident was sent to the hospital the same day after the physician was notified. A review of the significant change Minimum Data Set (MDS) completed on January 14, 2002 revealed that the resident required total assistance with all Activities of Daily Living (ADL's), which include bed mobility and transferring. The x-ray of the pelvis performed on the resident on January 14, 2002 revealed, "Left acetabular comminuted (crushed or broken into pieces) fracture." The resident was discharge from the hospital and readmitted to the facility on January 17, 2002. The resident was on a 5-pound Buck's traction and the physician ordered bed rest. The care plan to address the risk for falls was updated on January 17, 2002. It stated, "[o]bserve for attempts to climb OOB-evaluate need for pain meds (medications) when restless." During an interview with the Director of Nursing (“DON”) on June 20, 2002 at approximately 10:00 a.m., he stated that a low bed was added to the resident's care plan on January 25, 2002. The Buck's traction was discontinued on March 5, 2002 after a follow-up with the resident's orthopedic doctor. A review of the physician's report dated March 5, 2002 revealed under Findings, “healing acetabular £x L (left); Satisfactory alignment." The physician further documented, "May WBAT (weight bear as tolerated) for transfers; does not appear to be gait training candidate." The resident was started on physical and occupational therapy on March 6, 2002. A further review of the nurses! notes revealed the following incidents: 3/13/02 - The resident was found on the floor in the day room. The nurse's note stated the resident was "turned over in w.c. (wheelchair) on left side." The nurse's note further stated the resident denied pain on assessment; however, a "2 cm abrasion" of the scalp on the left side of his head, and "2 cm abrasion" on his left knee were noted. According to the nurse's note dated March 13, 2002 the resident's chair alarm and lap buddy were in place at the time of this incident. 3/18/02 - The resident was found by the Certified Nursing Assistant (“CAN”) sitting on the floor in his room. The nurse's note stated, "Resident sitting with back against bed near bottom of SR (side rail) on that side of bed with part of johnnie tucked into lower edge of that SR; 2 SR were up when checked pt and call bell on bed. Did not ring or call out." 3/21/02 - "lap tray removed for meals CNA states they continued to pass trays, turned from food cart to find res sliding down to floor against wall." 4/1/02 - "Res noted with scratches to both side of head. Origin unknown res unable to tell what happen due to confusion." 4/4/02 - "Heard alarm immediately went into rm (room) to find res out of bed holding onto side rail with both hands. Socks on feet sliding this nurse unable to hold resident; scratch on head reopened.” 4/5/02 - “res noted with laceration .3 cm on L 5th digit. Origin unknown." 4/25/02 - "RF/U (follow-up) laceration to Rt (right) index finger." 4/26/02 - "“Restlessness noted during the night. Found resident with head at the foot of the bed." 5/5/02 - "sm (small) scratch noted rt (right) ear apprx (approximately) .1 x .1 cm." 5/13/02 - "Resident sitting in w/c (wheelchair) in hallway. Moderate amt. (amount) of blood noted to tray. Site coming from L 3rd finger; Origin of ST (skin tear) unknown." 5/13/02 - "Resident found on floor by CNA in rm. Found lying on R side in front of closet. SR x 2 were still up on bed & alarm was unpinned & laying in center of bed. Sm amt of bleeding noted from R ear. ST & laceration, hematoma (bruise) to head just above R ear; Band-Aid with TAO (dressing) applied to both right elbow skin tear and head abrasion." A review of the nurse's notes completed by the 3:00 p.m. ~- 11:00 p.m. shift nurse, on May 13, 2002, revealed the resident complained of pain on his right hip. The resident was sent to the hospital emergency room after notifying the physician. The resident was admitted for right hip fracture. A review of the resident's clinical record revealed no documentation to indicate that the resident's care plan to address his risk for falls or accidents was revised after several incidents in March, April and May 2002, to prevent injuries. There is no documentation to indicate that current interventions were reviewed for effectiveness and alternative measures to supervise the resident were attempted. During an interview with the administrative staff on June 19, 2002 at approximately 2:30 p.m., they stated that the resident was on a one to one supervision. However, after speaking with the nursing staff, the DON verified that the resident was not on one to one supervision. He stated that the staff assigned to supervise closely those residents at risk for falls were assigned four (4) residents each (1 to 4 ratio). The DON further stated that he could not find documentation to indicate that Resident #12 was included in this close supervision. There was no explanation as to why the resident was found on the floor by staff numerous times from March 13, 2002 through May 13, 2002. RESIDENT #15 Resident #15 was admitted to the facility December 17, 1998 with diagnoses including Convulsions, Affective Psychoses, Hypertension, Osteoporosis, and Diabetes Mellitus. During the initial tour at 7:20 a.m. on June 17, 2002, this resident was observed to be Sitting in a wheelchair near the nurse’s station on the 100 Wing. A personal alarm was attached to the resident's wheelchair but not clipped to the clothing of the resident. During the next five (5) minutes three (3) staff members were observed to pass by this resident without noticing that the personal alarm was not attached. At 7:25 a.m., a CNA approached the resident and asked the resident what time she wanted to take a shower. The CNA then walked away without attaching the personal safety alarm. The RAP (Resident Assessment Protocol) for falls completed on September 25, 2001 stated: "Will continue care plan as Res (Resident) has had fall in last 31 to 180 days." The mps (Minimum Data Set) completed on the same date coded this resident as independent with no setup or physical help from staff for transfers. The care plan of October 2, 2001, addressed the problem: "Safety deficit R/T (related to) Hx (history) of falls and limited mobility in left hand, DX (diagnosis) of Osteoporosis and poor safety awareness and refusal to walk.” Further documentation on the care plan addressed a fall on October 24, 2001 with no injury when the resident slid from her chair. On October 31, 2001, the approach of "encourage resident to ask for assistance was added to the care plan." The next fall occurred on November 2, 2001 and was documented on the care plan as a fall in the bathroom with no injury. No additional approaches were added to the care plan as a result of this fall. The next fall occurred on January 11, 2002 without injury and the documentation revealed the resident had “c/o (complained of) back pain x-ray of spine ordered." The x-ray was entered as an approach on the care plan for falls. The results of x-rays taken of the lumbar spine on January 11, 2002 are as follows: "There are compression deformities of T1l and T12." The T1ll and T12 deformities were characterized as "likely old." No other fractures were present. An entry on January 31, 2002 in the care plan showed: "fall - slid from shower chair, no injury." The approach added to the care plan to address this fall was "Chair to be turned 'backwards' when exiting shower room. Velcro straps around pt. (patient) while in shower chair at all times." A fifth fall was documented on the care plan on February 12, 2002. The resident fell transferring from the wheelchair to the bed but incurred no injury. The approach added to the care plan to address this fall was "cont. (continue) to remind to ask for assist." A sixth fall occurred on February 13, 2002. ‘The documentation on the care plan stated: "found sitting on floor ‘missed the chair'." The approach added to the care plan as a result of this fall was that therapy was notified, but that the resident refused therapy. A seventh fall occurred on March 6, 2002. A nurse’s note dated March 6, 2002 stated: "At 9:00 A.M., patient was found lying on the floor, face down. Resident complained that she was hurting all over, had back Pains, and pain in (L) (left) arm and knee...Resident stated that she fell asleep while in the wheelchair and fell over." The notes document that the resident was transported to the hospital and returned to the facility on the same day at 2:35 p.m. "Diagnoses: Compression fracture L2 and ankle sprain.” The resident received orders for Motrin 600 mg. (milligrams) 1 PO (by mouth) QID (4 times a day). As a result of the fall of March 6, 2002 the facility added the following new approaches to the care plan: (1) extenders added to wheelchair brakes; (2) continue to remind resident to ask for help; and (3) consult with physician, resident, and family regarding chair alarm. In a physical therapy evaluation performed on March 11, 2002 the physical therapist stated: "Resident at same functional level - self propels w/c (wheelchair) and transfers to toilet by self. C/O (complains of) pain in back from compression fracture - pain medication. Possible chair alarm to cue her not to get up by herself ..." A fall assessment was completed on March 18, 2002 with the resident determined to be at high risk. A physician's order for bed and Chair alarm each shift was obtained on March 20, 2002. A significant change MDS was completed by Evans Health Care on March 13, 2002, which documented the resident as being independent in transfers and having, moderate pain on a daily basis. The quarterly MDS completed on June 5, 2002 also coded the resident as remaining independent in transfers and having moderate pain daily. A review of the MAR (Medication Administration Record) for the month of March revealed that the resident was receiving two (2) Tylenol Extra Strength Tabs, 500 mg. each, for Osteoporosis at 8:00 a.m. The pain medication was ordered on July 21, 2001. This resident was also receiving 650 mg. of Tylenol on an as needed basis for generalized pain as well as Motrin. According to the nurse’s notes the resident complained of back pain on multiple occasions in the days following the fall. The MAR showed that the as needed Tylenol was administered to the resident forty- four (44) times during April and May. The nurses documented back pain on twenty-seven (27) occasions and pain or discomfort on the remaining occasions as reasons for administering the Tylenol. A review of the clinical record revealed a neurologist consultation on March 22, 2002. The documentation did not reveal who requested the consult (e.g., the facility, the resident or family member) . The resident’s daughter accompanied her to the consultation. The neurologist stated the following in the consultation report: "Her daughter reports that she had fallen several times years ago but that this seemed to have stopped for awhile and then over the last couple of months she has fallen at least twice a month. Daughter reports that she either falls out of her chair or in the bathroom when she transfers alone. She has hit her head but has never lost consciousness. No seizure activity is noted though she has a history of seizures. She has no aura. Daughter has noted that she clearly does not lock her wheelchair when she tried to get out of it....She has a burning sensation on her feet. She also sustained lumbar fracture with non- radicular low back pain. This was associated with one of her falls..." The neurologist also ordered the following plan: "PLAN: I have written a note to the nursing home that she should not be allowed to transfer independently, particularly in the bathroom. She now has an alarm on her wheelchair. She has refused physical therapy and consequently there is little else to offer, however she will start Neurontin 100 mg. hs (hour of sleep) building up to tid (3 times daily) over the next few days. We will check an MRI brain to rule out any new strokes other focal sources of her headache and other complaints. Follow up one month." A review of medication orders for this resident revealed that the Neurontin had never been administered as planned by the neurologist. There was no explanation in the medical record as to why this recommendation was not followed. A review of the resident's care plan revealed that the approach that the resident not be allowed to transfer independently had not been added to the care plan. This resident remained coded as independent with transfers on the MDS of June 5, 2002. The record documented that the MRI had been completed. No documentation appeared in the record that the follow up in one month had been done. The AHCA surveyor interviewed the DON and asked why none of the neurologist’s recommendations had been implemented by the facility. The DON stated he believed the attending physician did not want to implement the recommendations. However, the AHCA surveyor found no documentation in the medical record verifieng the DON’s belief. The AHCA surveyor observed the resident on three (3) different occasions without her safety alarm. The resident was observed without her alarm on June 17, 2002. On June 18, 2002 the resident was observed in bed but the safety alarm remained on her wheelchair. On June 19, 2002 the resident was observed in the hallway in a wheelchair without the safety alarm attached to her clothing. 17. Based on all of the foregoing, Evans Health Care violated 42 CFR § 483.25(h) (2), via Rule 59A-4.1288, Florida Administrative Code (2001), by failing to ensure that each resident received adequate supervision or assistance devices to prevent accidents. 18. Pursuant to Section 400.23(8) (b), Florida Statutes (2001), the foregoing is a class II deficiency because it compromised each resident’s ability to maintain or reach his or her highest practicable physical, mental, or psychosocial well- 16 being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 19. Pursuant to Section 400.23(8), Florida Statutes (2001), the foregoing is an “isolated” Class II deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or ina very limited number of locations. 20. Pursuant to Section 400.23(8) (b), Florida Statutes, an isolated class II deficiency warrants a fine of $2,500.00. COUNT III EVANS HEALTH CARE FAILED TO ENSURE THAT EACH RESIDENT RECEIVED SUFFICIENT FLUID INTAKE TO MAINTAIN PROPER HYDRATION AND HEALTH. 42 CFR $483.25 (4) (2001) Rule 59A-4.1288, Fla. Admin. Code (2001) CLASS II DEFICIENCY ISOLATED 21. AHCA re-alleges and incorporates by reference paragraphs one (1) through eight (8) above as if fully set forth herein. 22. On or about June 17-20, 2002 AHCA conducted a survey at Evans Health Care. An isolated class II deficiency was cited against Evans Health Care based on the findings below involving resident #14: RESIDENT #14 Based on clinical record review and interview with the DON and the Registered Dietician (“RD”), the facility failed to provide adequate hydration resulting in dehydration and a two (2) day hospital stay for Resident #14. Resident #14 was totally dependent on facility staff for hydration and nutrition. The resident was admitted to the hospital with dehydration, urinary tract infection, and fecal impaction as evidenced by an abnormal abdominal x-ray and abnormal lab results of elevated Blood Urea Nitrogen (BUN) and Creatinine. Evans Health Care failed to develop or implement a care plan for dehydration/fluid maintenance as indicated by the Resident Assessment Protocol (“RAP”) dated August 1, 2001. Evans Health Care failed to implement the Bowel Management Protocol documented on the medication record. A review of the clinical record revealed that Resident #14 was readmitted to the facility on February 11, 2002 with diagnoses from the hospital transfer form of "UTI" (urinary tract infection) and Fecal Impaction. A review of the nurse's note dated February 9, 2002 revealed that the resident was “throwing-up” and the physician order a "stat" lab (meaning do very soon). On February 9, 2002 at 9:30 p.m., the physician was notified by the facility that the resident continued to have more episodes of “throwing-up”. At 10:30 p.m. the resident was transferred via ambulance to the hospital. The attending physician documented the following on the resident's History and Physical dated February 10, 2002: “sent to the Emergency Room where ‘'he/she' was found to be dehydrated with a blood urea nitrogen of 51. She was also found to have a urinary tract infection. . X-ray of the abdomen showed evidence of feces in the colon. The patient underwent a manual disimpaction." 18 A review of the resident's clinical record by the AHCA surveyor revealed an annual assessment MDS (Minimum Data Set) dated July 25, 2001 which showed the resident as totally dependent on facility staff for eating and had limited range of movement of both right and left fingers and wrist. The resident's quarterly assessment MDS of January 9, 2002 and April 29, 2002, respectively, continued to show resident as totally dependent on facility staff for eating with limited range of movement for both right and left fingers and wrist. The resident's RAP summary dated August 1, 2001 showed that the resident triggered for the problem area of dehydration/fluid maintenance. Evans Health Care decided not to care plan for the problem and had the Dietary Department assess the problem area. The RD assessment on September 13, 2001 revealed, "Labs returned - 9/10/01- BUN ~ 29 - elevated (on Lasix); Creatinine 6 .s Will continue with current regimen. Encourage fluids." Reference range for BUN is 7-17mg/dl and Creatinine is 0.7-1.2mg/dl. Dehydration is indicated when the BUN/Creatinine ratio is greater than 25. Resident #14's BUN/Creatinine ratio on September 10, 2001 was 48. A review of the registered dietician note dated February 2, 2002 revealed, "Labs of 1/30/02 show BUN - 35 elevated - on Aldactone." A review of Resident #14's January Medication Record revealed no bowel movements by Resident #14 for the following seven (7) consecutive days: 1/13/02; 1/14/02; 1/15/02; 1/16/02; 1/17/02; 1/18/02; and 1/19/02. A further review of the January Medication Record revealed no documentation of bowel movements on 1/29/02, 1/30/02, and 1/31/02. A review of the February Medication Record revealed documentation of no bowel movement on February 1 and 2, 2002, and no documentation of bowel movement on February 3, 2002. A review of the January and February Medication Record for Resident #14 revealed the following Bowel Management Protocol: "NO BM DAY TWO GIVE 30 CC MOM." "IF NO BM DAY THREE GIVE ONE 10 MG DULCOLAX SUPPOSITORIES." "IF NO BM DAY FOUR GIVE FLEETS ENEMA . IF NO RESULTS CALL MD." The January Medication Record contained no documentation evidencing that the facility implemented the Bowel Management Protocol from January 13-19, 2002, the seven days the resident did not have a bowel movement. Additionally, the January and February Medication Records contained no evidence that the facility implemented the Bowel Management Protocol from January 29- February 3, 2003 as evidenced by the lack of documentation in the record as to whether the resident had a bowel movement. A clinical record review by the AHCA surveyor revealed that a laboratory test was conducted on February 6, 2002 with the following abnormal results: BUN = 52H (high) reference range 7- 17mg/dl and Creatinine = 1.2 reference range 0.7- 1.2mg/dl. The BUN/Creatinine ratio on February 6, 2002 was 43. The laboratory tests results conducted on February 9, 2002 were as follows: BUN = 52H (high) reference range 7-17mg/dl and Creatinine = 1.3H (high) reference range 0.7- 1.2mg/dl. The BUN/Creatinine ratio on February 9, 2002 was 40. Both the February 6 and 9 laboratory values were greater than the BUN/Creatinine ratio of 25, which is indicative of dehydration. Evans Health Care failed to implement measures to ensure that Resident #14 received sufficient fluid intake to maintain proper hydration and health. The AHCA surveyor interviewed the DON and RD on June 19, 2002 at 2:00 p.m. The interviews confirmed that Evans Health Care failed to care plan for dehydration/fluid maintenance between July 25, 2001 and February 10, 2002, when 20 Resident #14 was hospitalized for Dehydration, UTI, and Fecal Impaction. The RD said she is given laboratory test reports to review on a regular basis. Resident #14 was readmitted to the facility on February 11, 2002. Evans Health Care care planned for dehydration at this time. 23. Based on all of the foregoing, Evans Health Care violated 42 CFR § 483.25(3) via Rule 59A-4.1288, Florida Administrative Code (2001), by failing to ensure that Resident #14 received sufficient fluid intake to maintain proper hydration and health. 24. Pursuant to Section 400.23(8)(b), Florida Statutes, (2001) the foregoing is a class II deficiency because it compromised Resident #14’s ability to maintain or reach his or her highest practicable physical, mental, or psychosocial well- being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 25. Pursuant to Section 400.23(8), Florida Statutes (2001), the foregoing is an “isolated” Class II deficiency because it affected one or a very limited number of residents, involved one or a very limited number of staff, or occurred only occasionally or in a very limited number of locations. 26. Pursuant to Section 400.23(8) (b), Florida Statutes, an isolated class II deficiency warrants a fine of $2,500.00. 21 CLAIM FOR RELIEF WHEREFORE, AHCA respectfully requests the following relief: 1) Make factual and legal findings in favor of AHCA on Counts I, II, and III; 2) Impose a $7,500.00 civil penalty against Evans Health Care pursuant to Sections 400.102 (1) (d) and 400.23(8) (b), Florida Statutes (2001); and 3) Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2001). NOTICE Evans Health Care hereby is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Plorida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Lori c. Desnick, Senior Attorney, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. 22 EVANS HEALTH CARE HEREBY IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS ADMINISTRATIVE COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE ADMINISTRATIVE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY AHCA. THE REQUEST FOR HEARING MUST BE RECEIVED BY AHCA WITHIN TWENTY-ONE (21) DAYS FOLLOWING RECEIPT OF THE ADMINISTRATIVE COMPLAINT BY EVANS HEALTH CARE. Respectfully submitted on this laa, day of February 2003. de CO Lori C. Desnick, Senior Attorney Fla. Bar. No. 0129542 Agency for Health Care Administration Building 3, Mail Stop #3 2727 Mahan Drive Tallahassee, Florida 32308 (850) 922-8854 (office) (850) 921-0158 (fax) 23 CERTIFICATE OF SERVICE — eee Se eet I HEREBY CERTIFY that one original Administrative Complaint has been sent by U.S. Certified Mail, Return Receipt Requested, (return receipt # Woe FS7S AGF QOS C F S53 ) to Elizabeth Ann Mackewich, Administrator, Evans Health Care Associates, LLC @/b/a Evans Health Care, 3735 Evans Avenue, Ft. Myers, Florida 33901, and that a true and correct copy of the Administrative Complaint has been hand delivered to Donna H.: Stinson, BROAD and CASSEL, 215 South Monroe Street, Suite 400, P.O. Drawer 11300, Tallahassee, Florida 32302, Attorney for Evans Health Care Associates, LLC d/b/a Evans Health Care, on this (Sal day of February 2003. ches CD LORI C. DESNICK, ESQUIRE 24

Docket for Case No: 03-001566