STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: AHCA No.: 2003001504 v. Return Receipt Requested: 7000 1670 0011 4849 3302 PUNTA GORDA MEDICAL INVESTORS 7000 1670 0011 4849 3319 LIMITED PARTNERSHIP, d/b/a LIFE 7000 1670 0011 4849 3326 CARE CENTER OF PUNTA GORDA >: - ' OD [le5Y Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Punta Gorda Medical Investors Limited Partnership, d/b/a Life Care Center of Punta Gorda (hereinafter “Life Care Center of Punta Gorda”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2002) (hereinafter “Fla. Stat.”), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose and maintain the Agency’s administrative fine of $1,000.00 pursuant to Section 400.23(8), Fla. Stat., for the protection of the public health, safety and welfare. 2. This is an action to impose and maintain the Agency’s assignment of a Conditional Licensure status to Life Care Center of Punta Gorda, pursuant to Section 400.23(7) (b), Fla. Stat. JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.c. 4, Venue lies in Charlotte County, pursuant to Section 400.121(1)(e), Fla. Stat., and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part Il, Fla. Stat. and Chapter 59A-4 Florida Administrative Code. 6. Life Care Center of Punta Gorda operates a 180 bed skilled nursing facility located at 450 Shreve Street, Punta Gorda, Florida 33950. Life Care Center of Punta Gorda is licensed as a skilled nursing facility; license number SNF12940961, certificate #9933. Life Care Center of Punta Gorda was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I LIFE CARE CENTER OF PUNTA GORDA FAILED TO ENSURE THAT SERVICES PROVIDED OR ARRANGED BY THE FACILITY MUST MEET PROFESSIONAL STANDARDS OF QUALITY AND BE IN ACCORDANCE WITH EACH RESIDENT’S WRITTEN PLAN OF CARE. TITLE 42, SECTION 483.20(k) (3), CODE OF FEDERAL REGULATIONS, as incorporated by RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE. (RESIDENT ASSESSMENT) UNCORRECTED CLASS III DEFICIENCY 7, AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 8. During the Annual Health Re-certification and Licensure Survey conducted by the Agency on 01/13/03 through 01/16/03 and based upon record review and interview, the Agency found that Life Care Center Of Punta Gorda failed to ensure that services provided or arranged by the facility must meet professional standards of quality and be in accordance with each resident’s written plan of care. The Agency found that the facility failed to assure that medications were administered correctly/in accordance with physician’s orders, to 2 of 21 sampled residents (Residents #7 and #17) and 1 random sampled (RS) resident (RS Resident #26). The findings include the following, to wit: (a) During a review of the clinical record for Resident #7, it) was noted that the resident had a documented allergy to “Levaquin.” (bo) A physician order dated December 10, 2002 shows an order for "Levaquin 250 mg. tablet P.O. (by mouth) QD (once a day) x 7 days." (c) Nurse's notes dated December 10, 2002 at 10:45 A.M. states, "ABT (Antibiotic Therapy) started for UTI (Urinary Tract Infection). VS (Vital Signs) 97.5 - 71 - 24 - 117/64." (d) A review of the MAR (Medication Administration Record) showed documentation of the resident receiving a dose of the Levaquin at 10:45 A.M. on December 10, 2002. The MAR also documented in the "Allergy/Notes" area that the resident is allergic to Levaquin. (e) Nurse's notes dated December 11, 2002 at 9:30 A.M. stated, "resident allergic to Levaquin. Discussed with ARNP (Advanced Registered Nurse Practitioner) that resident received dose of Levaquin yesterday no adverse effects noted. Received order to D/c (Discontinue) Levaquin. Cipro 500 mg. Q (every) 12 hours x 7 days and Celebrex 200 mg. PO QD." (f) A physicians order dated December 11, 2002 at 9:35 A.M. reads, "D/C Levaquin. Start Cipro 500 mg. QO 12 hours x 7 days for UTI ~ Celebrex 200 mg. QD for OA (Osteoarthritis) ." (g) On December 11, 2002 at 7:00 P.M., a new order for "Bactrim D.S. 1 BID (Twice a day) with food Po." was written by the attending physician. There was not an order to discontinue the Cipro. However, review of he MAR revealed the Cipro being D/C'd (discontinued). (h) A nurse's note at 9:30 A.M. on December 12, 2002 stated, "ARNP informed that Cipro is in the Levaquin family and ABT was changed to Bactrim DS 1 BID." Received clarification order as to stop date x 7 days. Pharmacy notified. No adverse effects noted. VS 98 - 70 - 20 - 132/72. Fluids encouraged and taken." 9. During record review for Resident #17, it was noted the attending physician on 10/14/02 ordered, "Calcium with vitamin D 600-125 PO Q HS (Hour of Sleep) ." (a) A review of the MAR for October, November, December, and January revealed the medication was given as ordered. (bo) Interview on January 15, 2003 with a staff member and a check of the medication cart revealed the medication delivered to this resident was taken from the stock medications. The bottle shown to the surveyor by the staff member as being the medication given to Resident #17 stated, "Calcium with Vitamin D 600-200." When questioned by the surveyor, the staff member stated "that is the dose that is supplied by the pharmacy" and she didn't realize it differed from the actual dosage ordered. 10. During the medication pass observation on 1/14/03 at 9:05 A.M., on the Captains Cove Unit, the Licensed Nurse dispensed Calcium 500 mg. with Vitamin D to Resident #26. The physician had ordered Calcium with Vitamin D 600-125 mg. on 8/30/02. An interview with the Pharmacist Consultant on 1/14/03 at 10:00 A.M., confirmed that the physician had ordered the specific dose of 600 mg. of Calcium and 125 mg of Vitamin D. The Pharmacist reviewed the stock medication room and confirmed that the facility did not carry the prescribed dose of Calcium with Vitamin D and that the attending physician should have been notified of this fact on 8/30/02. (a) An interview with the Medication Nurse on 1/14/03 at 10:15 A.M., confirmed that the wrong dosage had been given to the resident. Date to be corrected by: 02/16/03. ll. When the follow-up was conducted on 2/17/03 through 2/18/03, the Agency again found that Life Care Center Of Punta Gorda failed to ensure that services provided or arranged by the facility must meet professional standards of quality and be in accordance with each resident’s written plan of care. The deficiency was found uncorrected based on observation, record review and staff interview, as the facility failed to ensure that medications were administered according to physician's orders for 1 (Resident #4) of 14 sampled residents and that the physician was notified of significant weight changes in 1 (Resident #42) of 14 sampled residents. Findings include: (a) Record review for Resident #4 revealed that the physician had an order dated 1/31/03 for Senna one tablet every day. The resident had a diagnosis of Alzheimer's and Constipation and had prn orders for other laxatives. (b) Review of the physician orders for February revealed that facility staff hand copied the Senna order on it. Review of the Medication Administration Record (MAR) for February revealed that Senna was not listed. (c) Interview with the Director of Nursing on 2/17/03 revealed that there "must have been a transcription omission." (dq) Review of the Activity of Daily Living (ADL) flow record for February revealed that the resident did not have a bowel movement (BM) on February 1 through 4, The record documented 0 on all three shifts for those days. (e) Review of the MAR prn (as needed) record sheet revealed that Milk of Magnesia (MOM) 30 cc by mouth at bedtime if no BM in 3 days. (£) Interview with the staff nurse who works the 3-11 shift revealed she had not given the MOM although the resident did not have a bowel movement for 4 days. She confirmed there was no documentation that any medication was given or that the physician order was followed. She stated that something must have been given and not documented because on 2/5/03 she had 2 bowel movements. 12. Record review for Resident #42 revealed that the resident was admitted to the facility 1/2/03 with diagnosis including, but not limited to, Edema and CHF (Congestive Heart Failure). The resident is on the following medications related to his CHF: Lasix 80 mg. twice a day (a diuretic), Cardizem CD 120 mg. every day (an antianginal), Digoxin 0.25 mg. every day (an inotropic) and Prinivil 5 mg. every day (an antihypertensive). One of the signs and symptoms of an exacerbation of CHF is, edema in lower portions of the body resulting from venous stasis and reduced outflow of blood (Tabors's Cyclopedia Medical Dictionary). Possible complications include cardiac arrhythmias, Myocardial Failure, Pulmonary Infarction and Pneumonia. Standard nursing practice for a resident with a diagnosis of CHF is to monitor edema, intake and output, heart and lung sounds and report to the physician a weight gain of more than 2 to 3 pounds in a few days for possible needed adjustments in medications and/or treatment plan (The Lipin Manual of Nursing Practice). (a) The resident's body weight on admission to the facility was documented as 461.2 pounds. There is no plan for a weight reduction program indicated in the clinical record, rather, the Nursing Care Plan dated 1/23/03 and updated 2/11/03 lists the following as one of the approaches: encourage food/fluid consumption as needed. On 1/20/03, the resident's body weight was documented as 419 pounds, an apparent loss of 42.2 pounds or 9% body weight in 18 days. {b) Per interview with the DON (Director of Nursing), CD (Certified Dietary Manager) and MDS (Minimum Data Set) Coordinator on 2/18/03 at approximately 3:00 P.M., the DON stated that as per the facility's Plan of Correction from the Annual Survey, the facility's scales were calibrated and residents were reweighed as of 1/20/03 for an accurate weight, as the facility believed that the recorded weights prior to 1/20/03 were not accurate. (c) On 2/7/03, the resident's weight was recorded as 420 pounds; on 2/10/03, 3 days later, the resident's weight was recorded as 434.6 pounds, a gain of 14.6 pounds or 3.4% body weight, a possible indicator of an exacerbation of CHF. There is no indication in the clinical record that the physician was notified of this weight gain. (d) Nursing notes dated 2/11/03 through 2/18/03 frequently documents that the resident's lower extremities are red or discolored and edematous (swollen/fluid filled) but do not specify how much edema is present. (e) There is a nutritional progress note entered by the CDM dated 2/11/03 that acknowledges that the resident has had a 14.6 pound weight gain in 1 week and states that the resident is consuming 100% of meals, orders out at times, edema is present and the plan is: Continue with weekly weights until stable. (f£) During the 2/18/03 interview with the DON, CDM and MDS Coordinator, the CDM was asked, what does continue weekly weights until stable mean? The DON replied that since the facility believed weights prior to 1/20/03 were inaccurate and the scales were recalibrated, they were unsure of the accuracy of weights and were waiting to see if they now stabilized. When asked if she thought it were 10 important to report to the physician, a weight gain of 14.6 pounds in less than a week in a resident with a diagnosis of CHF, she stated that the ARNP (Advanced Registered Nurse Practitioner) had likely seen and assessed the resident since the weight gain. (g) Review of the ARNP progress notes revealed that the ARNP had seen the resident on 2/12/03 and documented the resident's weight as 419 pounds, indicating that she was unaware of the 14.6 pound weight gain. The progress note states that the resident's legs are very edematous with 2+ edema but does not mention the resident's lung sounds. The plan is: Continue current treatment plan. (h) The ARNP joined the group interview on 2/18/03 at approximately 4:00 P.M., and explained the resident's non-compliance with diet, etc. and explained that it was difficult to assess the amount of the resident's edema due to his obesity. She was asked by the surveyor, "If you were a staff nurse and had this resident, who has a diagnosis of CHF and is on 80 mg. of Lasix twice a day, his legs are edematous but the amount of edema is difficult to assess due to his obesity and he has a weight gain of 14.6 pounds in 1 week, would you notify the physician?" She replied, "yes. (i) A staff nurse was brought in later, who explained that the resident is non-compliant with his diet and sodium restrictions and that the physician is aware of the resident's weight fluctuations and non-compliance, though this is not documented. The staff nurse left the room, then returned a few minutes later and stated that she had just spoken to the physician by phone. She stated that the physician confirmed that he was aware of the resident's weight gain and non-compliance with diet and that he could not adjust the resident's medications. She stated that the physician would come in this evening and write a note to that effect. 13. Based on the foregoing, Life Care Center of Punta Gorda violated Title 42, Section 483.20(k) (3), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as an uncorrected Class Ift deficiency pursuant to Section 400.23(8) (c), Fla. Stat., which carries, in this case, an assessed fine of $1,000.00. This uncorrected deficiency also gives rise to the Agency’s assignment of a conditional licensure status, pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7), Florida Statutes, Life Care Center of Punta Gorda shall post the license in a 12 prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit war CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess and maintain the Agency’s administrative fine of $1,000.00 against Life Care Center of Punta Gorda, in accordance with Section 400.23(8) (c), Fla. Stat. Cc. Assess and maintain the Agency’s assignment of a conditional license status to Life Care Center of Punta Gorda, in accordance with Section 400.23(7) (b), Florida Statutes. D. Award the Agency for Health Care Administration costs related to the investigation and prosecution of the case, in accordance with Section 400.121(1), Fla. Stat. E. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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, Ae— Kathryn F. Fenske, Esq. Assistant General Counsel Agency for Health Care Administration Florida Bar No. 0142832 8355 N.W. 53 Street Miami, Florida 33166 14 Copies furnished to: Harold Williams Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340 Fort Myers, FL 33901 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #33 Tallahassee, Florida 32308 (Interoffice Mail)

Docket for Case No: 03-001654