Lad STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 03 NAY -7 py 243 AGENCY FOR HEALTH CARE i ADMINISTRATION, ¥E Petitioner, AHCA No.: 2003000777 AHCA No.: 2003000202 Vv. Return Receipt Requested: 7000 1670 0011 4849 6525 LIFE CARE RETIREMENT 7000 1670 0011 4849 6532 COMMUNITIES, INC. d/b/a 7000 1670 0011 4849 6549 WATERFORD HEALTH CARE CENTER, 7 ope O> i657 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 Life Care Retirement Communities, Inc. d/b/a Waterford Health Care Center (hereinafter “Waterford Health Care Center”) pursuant to 28-106.111, Florida Administrative Code (2001) and Chapter 120, Florida Statutes hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $1,000.00 pursuant to § 400.23(8)(c), Florida Statutes. 2. This is an action to impose a conditional licensure rating effective December 26, 2002 pursuant to § 400.23(7) (b), Florida Statutes. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to §§ 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Palm Beach County, pursuant to §§ 120.57 and Section 121(1)(e), Florida Statutes and Chapter 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to skilled nursing facility licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4 Florida Administrative Code. 6. Waterford Health Care Center is a skilled nursing facility located at 601 Universe Boulevard, June Beach, Florida 33408 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I WATERFORD HEALTH CARE CENTER FAILED TO ADMINISTER ANTI- PSYCHOTIC MEDICATION WITH ADEQUATE MONITORING. TITLE 42 §483.25(1), CODE OF FEDERAL REGULATIONS AS INCORPORATED BY R. 59A-4.1288, FLA. ADMIN. CODE §400.022(1) (1), FLA. STAT. (QUALITY OF CARE) CLASS III 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Waterford Health Care Center participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulations 483. 9. During the standard survey conducted on November 20, 2002 and based on interview and clinical record review, it was determined that the facility did not administer anti-psychotic medication with proper indications for its use, including monitoring for targeted behaviors, interventions attempted, outcome of medication administration, and side effects, for one resident in the thirteen resident Survey sample (Resident #4). The findings include the following. 10. Resident # 4 had a physicians order for Haldol 0. 5mg every twelve (12) hours as needed for agitation. The order was written September 05, 2002. Review of the PRN (as needed) administration record for September, 2002, revealed the medication was administered September 06 (two times, possibly a third time), September 07 {once), September 09 (two times), September 10 (two times, possibly three times), September ll(two times, possibly three times), September 12 (one time), September 13 (two times), September 14 (one time), September 15 (one time), September 16 (two times, and September 17 (two times). Review of the nursing notes for the month of September and the PRN administration sheet did not consistently reveal the reason the medication was administered. There was documentation that the medication was given for agitation, but did not specify what type of negative behaviors the resident was displaying. Review of nursing documentation notes for September listed wandering, poor safety awareness, confusion, and insomnia as behaviors prior to the administration of this anti-psychotic. In addition, documentation was inconsistent as to interventions attempted to reduce the resident’s behavior prior to administration of the drug, as well as outcome of the drug administration and monitoring for potential side effects related to the administration of the anti-psychotic drug. Documentation in the nursing admitting notes, dated September 05, 2002, reveals that the admitting physician was going to order the Haldol for the resident’s anxiety. There was no documentation found in the physician notes as to the reason for ordering this anti-psychotic drug outside the guidelines for its use, or documentation of the medications visks/benefits. The resident admission assessment, completed September 16, 2002, lists the resident’s behaviors as wandering, occurring daily, and resisting care, occurring 1-3 days in the past seven days. Review of the nursing notes reveals inconsistent documentation as to the residents resisting care. The resident was receiving an anti-psychotic medication without adequate monitoring for negative behaviors, interventions, outcomes, and side effects, and without adequate indications for the use of the drug. ll. Resident # 4 was being given Geodon, an anti- psychotic, in September and October, 2002, as ordered by the resident's physician. The resident's diagnosis for the use of this drug was listed as alzheimers with psychosis. Review of the medication administration record (MAR), nursing notes, and behavior/intervention monthly flow record did not reveal consistent documentation as to the negative behaviors the resident was displaying prior to the use of the drug. Behaviors documented included wandering, confusion, poor safety awareness and insomnia. There was no documentation in physician notes as to why the drug was being used outside the guidelines, or risk/benefit statements on the use of the drug. In addition, the behavior monitoring sheet, used by facility staff to document behaviors, listed anxiety/restlessness as uw the indication for the use of the anti-psychotic drug. For the month of September, there was inconsistent documentation of interventions attempted prior to the use of the drug to reduce the resident’s behaviors, behaviors the resident was displaying to warrant the use of the drug, documentation of the outcome of administering the drug, or monitoring for potential side effects of the drug. The resident was also being given Risperdal, another anti-psychotic drug, from October 27-31, 2002, again, without adequate indications for its use, monitoring of behaviors, interventions attempted prior to administration, outcome of the administration of the drug, or monitoring for side effects of the drug. Interview was conducted with the Director of Nursing (DON) on November 18, 2002. The DON was asked if there was more consistent documentation as to behavior monitoring, or indications for the use of the anti-psychotic drugs. This surveyor was provided four days of documentation in the form of nursing notes of monitoring the resident’s behaviors when the resident was given Haldol. The documentation was devoid of adequate indications as to why the drug was used. There was no additional supportive documentation given to the surveyor as to indications for the use of the anti-psychotic drugs. The mandated correction date was designated as December 21, 2002. 6 12. During the follow-up survey conducted on December 26, 2002 and based on interview and clinical record review, it was determined that the facility administered anti-psychotic medications to one (1) resident in the survey sample (resident #1) without adequate monitoring of targeted behaviors which would indicate the need for this drug, monitoring for side effects, interventions attempted, or outcome. The findings include the following. 13. Resident # 1 was ordered by the physician to receive the anti-psychotic drug Geodon, 20mg by mouth two times daily on October 31, 2002. The drug dosage was reduced to 20mg due to the resident having increased rigidity, as noted in the physicians progress notes. Review of the Medication Administration Record (MAR) for November 20, 2002 (exit date of Standard survey) through December 26, 2002 (revisit date), revealed the resident received the Geodon, 20mg twice daily as ordered except December 25, 2002, at 8:30 P.M. (There was no documentation as to why this dose was not administered) Review of the behavioral monitoring sheets the staff utilize to record the behaviors displayed, interventions attempted to reduce the behavior, outcome, and side effects of the medication, were based on behaviors listed as "Restlessness/Anxiety". The medication listed for these behaviors was Ativan, 0.5mg, and Geodon, 20mg. There was no documentation in the clinical record as to the reason the Geodon was being monitored for behaviors outside the guidelines, as restlessness and anxiety are not indications for the use of the anti-psychotic drug Geodon. Review of the nursing notes for the period of November 20-December 26, 2002, revealed an entry on November 20, 1:30 A.M., stating the resident had increased restlessness, Ativan given with good effect. An entry on December 26, 2002, at 7:00 A.M., lists the resident as being very agitated, but there is no documentation of what behaviors are being displayed, or what interventions were attempted to reduce the behaviors. Another entry on December 26, 2002, at 11:30 A.M., documents the resident as being agitated, stating, "just leave me alone", and it is documented that the resident had increased restlessness. Ativan was given at 8:00 A.M. There is no documentation in the nurse’s notes or on the behavioral monitoring sheets of the resident being monitored for side effects of the medication, behaviors displayed that would indicate the reason for the drugs use, interventions, or outcome of the medication administration. The Director of Nursing (DON) was interviewed on December 26, 2002, at 11:00 A.M. It was asked if there was any evidence of the behavioral monitoring in the record. At 12:40 P.M., the DON was again asked if the behavioral monitoring was evidenced in the record, and it was stated no. It was pointed out to the DON that the monitoring sheet listed the drugs Ativan (an anxiolytic) and Geodon (an anti- psychotic), and the behaviors attempting to be controlled by the drugs as restlessness and anxiety. The drug Geodon was being monitored for behaviors outside the guidelines for the use of this drug and without adequate monitoring of side effects, interventions attempted to reduce the behaviors, and outcome. This is an uncorrected deficiency from the survey conducted on November 20, 2002. 14. Based on the foregoing, Waterford Health Care Center violated § Title 42 § 483.25(1), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Fla. Admin. Code and § 400.022, (1) (1), Florida Statutes, herein classified as a Class III violation which carries, in this case, an assessed fine of $1,000. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. PRAYER 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 Tf. B. Assess against Waterford Health Care Center an administrative fine of $1,000.00 for the one (1) Class III violation as cited above. Cc. Assess against Waterford Health Care Center a conditional license in accordance with Section 400.23(7), Florida Statutes. D. Assess costs related to the investigation and prosecution of this matter, if applicable. E. Grant such other relief as the 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, Manchester Building, First Floor, 8355 NW 5374 Street, Miami, Florida 33166; Alba M. Rodriguez. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 10 Chaar th fe sger pes Alba M. Rodriguez @ ~) Assistant General Counsel Agency for Health Care Administration 8355 NW 53° Street Miami, Florida 33166 Copy to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive West Palm Beach, Florida 33407 (Interoffice Mail} Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes, Waterford Health Care Center shall post the license in a prominent place that is 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 “A” EXHIBIT “A” Conditional License License # SNF 1587096; Certificate No.: Effective date: 12-26-2002 Expiration date: 03-31-2003 9720 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Frank David Kellogg, Administrator, Waterford Health Care Center, 601 Universe Boulevard, Juno Beach, Florida 33408; Life Care Retirement Communities, Inc., 1600 HUB Tower, 699 Walnut, Des Moines, Iowa 50309; CT Corporation System, 1200 S. Pine Island Road, Plantation, Florida 33324 on this ae day of March, 2003. a . wee ty Noon 4 Alba M. Rodriguez a)

Docket for Case No: 03-001657