STATE OF FLORIDA ae AGENCY FOR HEALTH CARE ‘OMIMSTRATIONS HAY 39 PH 2: 39 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, CASE #2003001 031 O>D- ASS VS. OCALA MEDICAL INVESTORS, LLC, d/b/a LIFE CARE CENTER OF OCALA, Respondent. / ADMINISTRATIVE COMPLAINT. COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (*“AHCA” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against OCALA MEDICAL INVESTORS, LLC d/b/a LIFE CARE CENTER OF OCALA (“Respondent”), pursuant to Sections 120.569 and 120.57, Florida Statutes, and alleges: NATURE OF ACTION 1. This is an action to impose an administrative fine upon Respondent. JURISDICTION AND VENUE 2. AHCA and the Division of Administrative Hearings, in the event a formal hearing is requested, have jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. 3. Venue shall be determined pursuant to Rule 28-106.207, Fla. Admin. Code. PARTIES 4, AHCA is the regulatory agency responsible for licensure of skilled nursing facilities and enforcement of all applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part IJ, Florida Statutes, and; Chapter 59A-4, Fla. Admin. Code, respectively. 5. Respondent, OCALA MEDICAL INVESTORS, LLC, owns and operates askilled nursing facility in the state of Florida. The facility, LIFE CARE CENTER OF OCALA (“Facility”), is a 120-bed skilled nursing facility located at 2800 SW 41* Street, Ocala, Florida 34474. Respondent is licensed as a skilled nursing facility, having been issued license #SNF130470993. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulation, statutes and rules. COUNT I ISOLATED CLASS I VIOLATION FOR FAILURE TO ENSURE THAT RESIDENT WAS FREE FROM UNREQUIRED CHEMICAL RESTRAINTS, OR ALTERNATIVELY, FOR FAILURE TO PROVIDE RESIDENT WITH ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS (FALL) [42 CFR §483.13(2) and 42 CFR § 433.25(h) and Rule 59A-4.1288, Fla. Admin. Code] - 6. AHCA tre-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herem. The Alleged Violation 7. The regulatory provisions of the Code of Federal Regulations that are pertinent to this alleged violation, which provide alternative legal grounds for a determination that a violation exists here, which regulations are applied in Florida pursuant to Rule 59A-4.1288, Florida Administrative Code, include but are not limited to, the following: [42 CFR] §483.13 Resident behavior and facility practices. (a) Restraints. The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms. * * * [42 CFR] § 483.25 Quality of care. Each resident must receive and the facility must provide 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. * * * (h) Accidents. The facility must ensure that — * * * (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 8. On or about February 4 ~ 5, 2003, AHCA surveyors conducted a survey of Respondent's facility, which included a review of records, including nursing notes and facility assessments and incident reports, and staff interviews as were appropriate. 9. Among other things, this survey revealed that one of Respondent's residents, identified here as Resident #11 (for purposes of compliance with federal law protecting the private health information of residents), fell out of a shower chair on December 31, 2002, hitting his/her head on the floor, from which fall he/she sustained an injury requiring eleven (11) stitches to his/her forehead. 10. Upon closer scrutiny of the facts regarding the above-referenced incident, AHCA’s investigation. of this incident revealed the following pertinent facts: a. Resident #11 {hereinafter “the resident”] was admitted to the facility on 10/31/01 with a diagnosis of depression, hypertension, Parkinson and organic brain syndrome (OBS). b. The clinical record for the resident includes a nursing note for 7/ 19/02 that indicates that the resident was very combative with staff during care. c. The facility completed a Fall Risk Assessment on the resident on two dates prior to the fal] and on the day of the fall, respectively dated. 07/01/02, 10/22/02 and 12/31/02. All three assessments rated Resident #11 as “at HIGH RISK for potential falls.” [Emphasis added.) The 12/31/02 assessment evaluated her as more at risk than the previous two assessments. The 12/31/02 assessment also notes that the resident fell twice in the previous three (3) months. d. The resident’s clinical record revealed an 11/3/02 nurse’s note indicating that when the resident’s torso support was removed, the resident was being monitored for a left upper forward lean (upper extremity weakness). e. The nursing notes dated 12/31/02 reveal that on that date the resident fell out of the shower chair hitting her/his head on the floor. The resident was sent to the hospial where 11 stitches were placed to a laceration on the left side of the forehead. f. The iacility’s incident report dated 12/31/02 (8:00 pm) reveals that the resident had seen given Remeron 7.5 mg, Haldol 0.5 mg, and Ambien 5 mg prior to the incident. g. The interview with the long term care coordinator on 2/4/03 at 3:50 p.m. revealed that the Certified Nursing Assistants (CNA) set the bath time for later in the evening after supper for residents that are combative and unable to communicate their needs. h. During the interview with the 3-11 p.m. medication nurse on 2/4/03 4:00 p.m., she stated that she was aware of Resident #11’s abusive behavior towards staff when they attempt to do personal care (toileting, bathing). She further stated that this resident is routinely given Remeron 7.5 mg, Haldol 0.5 mg, and Ambien 5 mg between 7:30 — 8:00 p.m., just before she is given a bath. i. Upon AHCA’s interview on 2/4/03 at 5:45 p.m. with the resident’s assigned CNA fer 12/31/02, the CNA stated that the resident is given a bath at 8:00 pm or later because she cannot bathe the resident if the resident has not taken the medication. The CNA indicated that the resident will fight and squeeze her arm if she attempts to provide care without the medication. j. The CNA stated that the resident was very sleepy and kept slumping forward on 12/31/02 during the shower and that she was unable to keep the resident frora falling out of the chair. k. The resident’s physician’s orders reveal that the Remeron was prescribed for depression, that Haldol was prescribed for OBS and that the Ambien was prescribed for insomnia. The physician’s orders, dated 06/28/02, include comment that “RESIDENT IS NOT AWARE OF MEDICAL CONDITION/DIAGNOSIS DUE TO RESTRAINTS.” 1. The resident’s minimum data set (MDS) dated 1/15/02 reveals that the resident is totally dependent in carrying out daily bathing activity. m. The resident’s minimum data (MDS) dated 1/15/03 reveals that the resident, though triggered for physical abusive behavior towards staff, is easily re- directed. n. The Resident Assessment Instrument (RAI) dated 1/15/03 did not reveal any documented evidence that the facility had assessed the resident’s abusive behavior. o. The Care Plan dated 1/15/03 reveals that the resident was assessed for activities of daily living and psychotropic medications; however, the goals and/or approaches did not reflect any concern about the resident’s combative/abusive behavior during care or about the administration of the psychotropic medications prior to bathing in order to prevent the combative/abusive behavior. p. On the printed report form of the Munroe Regional Medical Center Emergency Services, dated 12/31/02 and identified as pertaining to the resident, the printed form states just below the “Nursing/staff” signature line (signed by an RN), that “Ifa medication was prescribed for you that may effect your alertness, do not ... perform activities requiring alertness.” 11. Respondent knew, or should have known, that the resident was at risk for negative effects from the psyhchotropic medications given to the resident just before the resident’s fall on December 31, 2003. 12. Respondent knew, or should have known, that the resident needed extensive assistance in the performance of activities of daily living, including at the time of the fall on December 31, 2003, and including in particular, extensive assistance in bathing. 13. Respondent failed to ensure that the resident was free from chemical restraints imposed for purposes of discipline or convenience, which chemical restraints were not required to treat the resident’s medical symptoms at the time of the resident’s evening bathing. Respondent's conduct is in violation of 42 CFR §483.13(a), quoted previously above. 14, Inthe altemative, Respondent failed to provide the necessary care and services for the resident to attain or maintain her highest practicable physical, mental, and psychosocial well being, in that the facility also failed to ensure that the resident received adequate supervision and assistance to prevent the fall and injury which occurred on December 31, 2003. Respondent’s conduct is in violation of 42 CFR §483.25, specifically subparagraph (h)(2), quoted previously above. The Classification of the Alleged Violation 15. Upon AHCA’s determination that a violation exists, §400.23(8), Florida Statutes (2002), requires AHCA in a separate act to classify each alleged violation according to its “nature and scope.” 16. That referenced statute requires AHCA to determine if the alleged violation is “isolated, patterned or widespread.” Here, where the violation involves only one resident, the alleged violation is an isolated violation. 17. Subsection (8) of the referenced statute also requires AHCA to classify the alleged violation as within one of four (4) legislatively defined classes, ranging in seriousness from Class J, the most serious, to Class IV, the least serious. 18. Upon the application of the facts of this case to the four choices of classes, ABCA determined that the violation here constitutes a Class II violation, whether the ©@ @ violation is based upon the failure to comply with the above-referenced Resident Behavior and Facility Practices provisions, or alternatively, the Quality of Care provisions. 19. As to both of the statutory grounds pled here as the basis for establishing the alleged violation, Respondent's conduct compromised the resident’s ability to maintain or reach her “highest practicable physical, mental, and psychosocial well-being,” which establishes the violation is a Class II violation. AHCA further would show that the violation here: (a) resulted in a fall and injury to the resident that constituted “more than minimal physical, mental, or psychological discomfort to the resident” (and thus cannot be a Class III violation); and additionally (b) actually compromised (tather than “has the potential to compromise”) the resident’s ability to maintain or reach her “highest practical physical, mental, or psychosocial well-being” (4¢., the violation is a more serious violation than just a Class III violation). 20. Upon the establishment of the nature and scope of the violation, there is no discretion as to the amount of the administrative fine under the statute, The statute requires that the fine for this violation, as an isolated class II violation, is $2,500. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of AHCA that a violation exists, either of the referenced resident Behavior and Facility Practices provisions of the law, or alternatively, of the Quality of Care provisions of the law, 2. Factual and legal findings in favor of AHCA that the nature and scope of the proven violation is that it constitutes an isolated Class II violation; and 3. A recommendation to AHCA that the agency enter its Final Order requiring Respondent to pay an administrative fine in the amount of $2,500. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida 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 Lealand McCharen, Agency Clerk Agency for Heaith Care Administration Building #3, MSC #3 2727 Mahan Drive Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT RY RESPONDENT. FAYLURE TO COMPLY WILL CONSTITUTE AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted. Dated this } aL day of a 2003. p yyTv— Tom R. Moore, Esquire AHCA Senior Attorney Fla. Bar No. 097383 Counsel for Petitioner Agency for Health Care Administration Building #3, MSC #3 2727 Mahan Drive Tallahassee, FL 32308 (850) 922-5873 (office) (850) 413-9313 (fax) CERTIFICATE OF SERVICE AHCA, by and through its undersigned counsel, hereby certifies that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and Explanation of Rights Under Section 120.569, F.S.A. form, have been forwarded by certified mail, return receipt requested, to: John Michael Stover, Administrator, Life Care Center of Ocala, 2800 SW 41" Street, Ocala, Florida 34474, on this, the dt w day of WV \ff 4 , 2003. Wry Tom R. Moore, Esquire

Docket for Case No: 03-002005