Ca STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION os IS p., von “ hy Phew AGENCY FOR HEALTH CARE EE ew a ADMINISTRATION, “i Petitioner, AHCA No.: 2002047685 AHCA No.: 2003002356 Vv. Return Receipt Requested: 7000 1670 0011 4849 5764 GJS HOLDINGS, INC. d/b/a 7000 1670 0011 4849 5771 HALLANDALE REHABILITATION 7000 1670 0011 4849 5818 CENTER a - ’ QO 2>- 33649 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 GJS Holdings, Inc. d/b/a Hallandale Rehabilitation Center (hereinafter “Hallandale Rehabilitation Center”) pursuant to Section 28- 106.111, Florida Administrative Code 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 $7,500.00 pursuant to Section 400.23(8), Florida Statutes [AHCA No.: 2003002356]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7)(b), Florida Statutes [AHCA No. 2002047685]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106 Florida Administrative Code. 4, Venue lies in Broward County, pursuant to Section 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 nursing home licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Hallandale Rehabilitation Center is a skilled nursing facility located at 2400 East Hallandale Beach Boulevard, Hallandale, Florida 33009 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I HALLANDALE REHABILITATION CENTER FAILED TO PROVIDE A RESIDENT WITH THE NECESSARY CARE AND SERVICES TO MAINTAIN HIS/HER HIGHEST PRACTICABLE PHYSICAL WELL BEING. TITLE 42 SECTION 483.25, CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Hallandale Rehabilitation Center participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. The following is a description of the findings. 10. During the re-certification and re-licensure survey conducted between March 3, 2003 and March 5, 2003 and based on interview and record review, it was determined that the facility did not provide the necessary services to a resident (Resident #18) to maintain his/her highest physical well-being by failing to provide an antibiotic that was ordered for the resident. The resident had to be later transferred to the hospital with an elevated temperature and respiratory distress and to rule out sepsis. 11. Resident # 18 was readmitted from the hospital to the facility on 2/27/02. The resident was a ventilator dependent tracheostomy resident that was administered nutrition via a gastromy tube. The resident also had a central venous line to the "left side of neck" and a catheter to drain urine from the bladder. The resident was admitted with the following diagnoses: Respiratory Distress, Chronic Renal Failure, Anemia secondary to Gastrointestinal bleeding, Lung cancer, and Atherosclerotic Heart Disease. The nursing admission note documented that the resident had a "Stage IV sacral area with odor." 12. Included in the list of medications ordered on admission, the following antibiotic was noted: Amikacin 375 mg intravenous every 24 hours for seven days. “Peak and Trough after third dose." A physician's order dated 2/28/03 revealed the following: "Please send IV Amakacin. This is included in our per diem facility will pay for it." The nurse practitioner wrote an order on 2/28/03, "peak and trough after 3rd dose." A nurse's note dated 3/1/03 documented the following: "Pharmacy need a written letter from the administrator stating he will pay for intravenous antibiotic." 13. A review of the clinical record did not reveal any medication administration records (MARs) for February or March 2003. On 3/5/03 at 1:50 pm, medical records personnel revealed that she did not have the MARs for February and March for this resident. An administrative staff member was asked on 3/5/03 at 910 AM, 11 AM, and 2 PM for the MARs and each time it was confirmed that it could not be located. She continued to report that she checked all closed records in case it was misfiled, the current MARs to see if they were still in the book, and the nurse's station on 1 East, but they could not be located. Another administrative staff member was asked for the MARS on 3/5/03 at 1:55 PM and he revealed that they were "still looking for it." Interview with the administrator on 3/7/03 at 3 pm revealed that the MARs or any documentation to substantiate that the resident received any medications as ordered still could not be located. 14. The Resident was transferred back to the hospital on 3/3/03 (4 days after readmission). The order documented by the nurse practitioner that transferred the patient indicates, "Transfer to hospital. Diagnosis: Respiratory Distress, Fever. Rule out Sepsis." The last entry on the nurse's notes is dated 3/2/03. 15. Interview on 3/10/03 with a pharmacist from the pharmaceutical company the facility has a contract with revealed that their company never dispensed the antibiotic for this resident. The pharmacist reported that the antibiotic was net sent due to an issue regarding payment for the medication uw and due to problems with the facility's ability to obtain accurate labs to determine blood levels for the resident. The safety and efficacy of the antibiotic is determined upon accurate blood drug levels. If levels are too high, this antibiotic could cause toxicity affecting an individual's inner ear and kidneys. 16. Based on the foregoing, Hallandale Rehabilitation Center violated 483.25, Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which imposes an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. COUNT II HALLANDALE REHABILITATION CENTER FAILED TO ENSURE THAT TWO RESIDENTS MAINTAINED ACCEPTABLE PARAMETERS OF NUTRITIONAL STATUS SUCH AS BODY WEIGHT. TWO RESIDENTS EXPERIENCED SIGNIFICANT WEIGHT LOSS THAT WAS AVOIDABLE. 483.25(i) (1), CODE OF FEDERAL REGULATION (QUALITY OF CARE) CLASS II 17. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 18. During the re-certification and re-licensure survey conducted on March 5, 2003 and based on observation, record review, and interview, it was determined that the facility did not ensure the provision of consistent, adequate, services necessary to sustain and improve nutritional status and body weight for 2 of 11 residents sampled for weight loss and nutrition issues (Residents #9 and #8). The findings include the following. RESIDENT #9 19. Review of the clinical record for resident #9, on 3/4/03, revealed 8/28/02 admission diagnoses of HIV, history of Breast Cancer, Encephalopathy, Insulin dependent Diabetes Mellitus, and seizures. Further review of the clinical record revealed a Nutritional Assessment, completed by the facility Clinical Dietitian, which noted resident #9's height as 66 inches, and weight as 160 lbs. Ideal body weight (IBW) for the resident was determined to be 130 to 140 lbs. Nutritional care notes dated 8/30/02, completed by the facility Clinical Dietitian, documented resident #9's weight to be "120% of IBW" and "desirable". It was also noted that resident #9's weight was to be monitored weekly. Care plan #12, dated 8/30/02, completed by the facility Clinical Dietitian documented goal for the resident to "eat 75% of meals", with a noted approach to "feed patient". Care plan #12, also revealed a goal of "gradual weight loss until IBW range is reached” dated 11/13/02, to be achieved within "3 months". Review of the Clinical record revealed no Minimum Data Set (MDS) to coincide with care plan #12, dated 8/30/02. The MDS dated 11/11/02 revealed that resident #9 was able to "feed self with set up only" per section Gl h. for “eating”. Resident #9's weight was noted as 153 lbs. at the time. There was no current MDS available for further review. The facility MDS coordinator revealed on 3/4/03 that "the computer was down for 2 weeks...just fixed the computer last Friday. If the MDS is not in the chart, it's either because I'm waiting for signatures or it needs to be inputted in the computer." The list of MDS's submitted by the facility on 3/3/03 and again on 3/4/03 at 3:35 pm did not include the name of Resident # 9 as one that was currently being worked on, awaiting staff signatures, or pending input into the computer. Nutrition care notes completed by the facility Clinical Dietitian, 12/21/02, noted resident #9's weight to be 151.3 lbs. It was also noted that resident #9 had been hospitalized in October 2002, and "weight has been stable since readmission". 20. Review of resident #9's weight history is as follows: 8/30/02 160#s Nutrition Assessment 11/11/02 153#s MDS 12/21/02 151.3#s Nutrition Care Notes 1/03/03 142#s Weight Book 2/01/03 131#s Weight Book 3/04/03 126.3#s Observation of staff weighing resident 3/04/03 11:50 am. 21. There were no weekly weights available per facility Dietitian's recommendation 8/30/02. Weight loss period 1/03/03 through 3/04/03 reflects an 11.05% total. Weight loss period 8/30/02 through 3/04/03 reflects a 25.9% total. Care plan #12 and Nutritional Care notes were not updated to reflect this weight loss and current plan of approach. 22. Review of the Resident Daily Care record for December 2002 through March 3, 2003, notes residert #9's appetite as being good to excellent for the entire month of December, eating 75 to 100% of meals at Breakfast, Lunch, and Dinner. Review of the Resident Daily Care record for January 2003 through March 3, 2003 note a decline in appetite for the resident to poor, eating only 25%. All of the Resident Daily Care records, December 2002 through March 3, 2003, note eating ability as "I" for independent. Observation of the resident on 3/04/03, at 12:21 pm, at the Lunch meal, and on 3/05/03, at 8:15 am at the Breakfast meal revealed the resident eating without assistance, consuming 25 to 30% of meal. served. Interview with the Unit Manager revealed that the resident eats without assistance, and was not eating "much". The Resident Daily Care records were reviewed with the Unit Manager, and it was determined that Nutritional Intervention should have taken place the period of 1/03 through 3/03/03, to include assistance with feeding. 23. Interview with the facility Clinical Dietitian on 3/05/03, at 9:40 am, and 12:45 pm, revealed that resident #9 had a decline in eating with no continued intervention and stated "there should have been better communication". It was also noted that the resident should have been weighed weekly, but "sometimes 1 or 2 residents slip through the cracks". The facility Clinical Dietitian mentioned documenting in the resident's clinical record Nutritional Care notes on 3/04/03, which noted "undesired weight loss". RESIDENT #8 24. Resident #8 had been admitted to the facility on 01/08/03 with diagnoses, which included multiple arm fractures, s/p fall, HIN, Hyperlipidemia, anxiety and GERD. A 10 review of the resident's clinical record revealed the resident weighed 110 pounds at admission. A review of the weekly weight log, indicated resident #8 weighed 101 lbs. on 01/13/03, and 100 lbs. on 01/20/03, a weight loss of 10 pounds in a two-week period of time. Further review of the clinical record noted that dietary had not addressed the significant weight loss and had coded the minimum data set (MDS) assessment, dated 01/23/03, with a weight of 110 pounds with no weight change indicating resident is within their ideal body weight and therefore did not require any further interventions. 25. On 03/04/03, the resident was observed being weighed and had a weight of 95 pounds. 26. Based on the foregoing, Hallandale Rehabilitation Center Nursing violated 483.25(i) (1), Code of Federal Regulation, as incorporated by Rule 59A-4.1288, Florida Administrative Code herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which imposes an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statute. COUNT III HALLANDALE REHABILITATION CENTER FAILED TO PROVIDE A RESIDENT WITH SUFFICIENT FLUID INTAKE TO MAINTAIN PROPER HYDRATION 483.25(j), CODE OF FEDERAL REGULATION RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE’ (QUALITY OF CARE) 11 CLASS II 27. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 28. During the re-certification and re-licensure survey conducted on March 5, 2003. and based on observation, interview, and record review, it was determined that the facility failed to provide 3 of 8 residents sampled for dehydration (Residents # 4, 6, and 13), with sufficient fluid intake to maintain proper hydration and health. The findings include the following. RESIDENT #4 29. During the initial tour of the facility on 3/3/03, resident #4 was noted in bed mouthing the words "agua, agua" (which means ‘water, water,' in Spanish) after noting a staff nurse and AHCA surveyor in his sight. While mouthing these words, the resident had his hands together, palm-to-palm, in front of him at chest level. The resident was noted to have a tracheotomy and tube feeding infusing via a gastrostomy tube. The staff nurse present during this observation reported to the surveyor that "he's always asking for water, but he can't have any" and proceeded to walk out of the room. 30. A dietary assessment dated 1/11/03 was noted in the resident's clinical record that documents "Resident on 12 diuretic therapy and KCL replacement...Resident at risk for dehydration..." No other dietary notes were noted since this initial assessment. 31. Review of the current care plans in the resident record revealed the following: 1/11/03 At risk for alteration in nutrition and significant weight changes, resident unable to consume food/fluids PO due to Tracheotomy, dysphagia. Goals included Adeq. Hydrated BUN WNL. Approaches included: Monitor labs as available. Notify MD of abnormal values. No evidence was noted that this care plan was reviewed or revised subsequent to the initial date of 1/11/03. 32. The resident's first admission to the facility was 1/6/03. He was transferred to the hospital on 2/7/03 due to a fever and increased white blood cell count. Hospital diagnoses listed included pneumonia and urinary tract infection. After a 5-day admission in the hospital, the resident was readmitted to the facility on 2/12/03. Further review of the resident's clinical record revealed the following lab values collected on 2/17/03: BUN 43 (normal reference range 8-23) Creatinine 1.1 (normal reference range 0.7-1.4)} 33. A physician's order dated 2/19/03 was noted for "Water flushes Q 4 hrs, CBC, SMA? 2/24/03." The March Medication Administration Record (MAR) documented "Flush with 13 H20 200 cc Q 4 hrs 7A-7P," but did not specify at what specific times the flushes were supposed to be administered. 34. Lab values noted to be collected on 2/24/03 revealed: BUN 87 (normal reference range 8-23) Creatinine 1.4 (normal reference range 0.7-1.4) 35. A progress note dated 3/3/03 written by a nurse practitioner working for the resident's pulmonologist revealed "Azotemia-worsening... intravenous fluids, check labs...elevated Potassiun, Discontinue Aldactone” A corresponding physician's order dated 3/3/03 documented "Discontinue Aldactone. Stat CBC, SMA7..... IV fluids D51/2 NS 50 cc/hr". Review of the March MAR revealed documentation that the resident was still administered the diuretic Aldactone on 3/4/03, even after it had been discontinued the day prior. 36. Review of the MAR for March 2003 revealed the following documentation "Nutrivent 55 cc/hr." However, the order was changed on 2/12/03 to 60 cc/hr. In addition, review of the resident's February MAR revealed that on 2/12/03, the resident was to have his PEG flushed with 30 cc H20 before and after administering medications. That information was not noted on the March MAR. 37. Observation of the resident on 3/4/03 at 1030 am revealed no IV fluids infusing into the patient as the order 4 reads. Interview with the staff nurse on 3/4/03 at 1040 am revealed she had no knowledge of the order for the IV fluids and reported that she was not told about it during report with the nurse from the shift prior. Review of the facility's 24- hour report revealed no documentation regarding the order or why the IV was not started. Interview with the facility DON on 3/4/03 at 1045 am revealed she was the person responsible for starting all IV's ordered but was not aware of this order and reported that she would start the IV. 38. On 3/5/03 at 835 am, the resident was observed to be without any fluids infusing intravenously nor to have an IV site. The facility DON reported during interview of 3/5/03 that she was unable to start the IV and obtained an order to discontinue the IV fluids yesterday afternoon. A review of the resident's clinical record revealed an order dated 3/4/03 to "discontinue IV fluids and call Dr. with labs result now." The lab results crdered on 3/3/03 were not in the chart. Interview with the DON on 3/5/03 at 840 am revealed that all labs ordered on 3/3/03 were not drawn. The DON also reported that she called the lab company on 3/3/03 and was told that a staff member had called in, and they had no one to send to draw labs ordered, so the labs were drawn the next day 3/4/03. When asked about the lab results for those drawn for this resident on 3/4/03, she reported that the results had not come in yet and she was going to follow-up with the results. 39. Lab values collected on 3/4/03 were obtained from the facility on 3/5/03 and indicated the levels had worsened to the following: BUN 133 (normal reference range 8-23) was 87 on 2/24. Creatinine 1.7(normal ref. range 0.7-1.4) was 1.4 on 2/24. Sodium 165 (normal reference range 135-149) was 147 on 2/24. Chloride 119 (normal reference range 98-114) was 106 on 2/24. 40. After reviewing the above lab values on 3/5/03, a nurse practitioner for the resident's pulmonologist wrote an order for the resident to be transferred to the hospital emergency room. 41. During interview on 3/5/03, the nurse practitioner revealed that the order for the IV fluids ordered for the resident was not carried out, and that the staff did not notify him that the IV could not be started on the resident until the day after the IV had been ordered. In addition, the nurse practitioner reported that he was not notified of the lab results as he requested on 3/4/03 until he came in on 3/5/03. RESIDENT #6 42. Resident #6 was admitted to the facility on 2/18/03 with anoxic brain damage, near drowning and respiratory failure secondary to a MVA. She was currently receiving a gastrostomy 16 tube feeding for nutrition at 60 cc/hr. On 3/1/03, her flushes were increased to 250 cc H20 every 4 hours in addition to her feeding. She was also noted to have a tracheotomy with cool aerosolized oxygen. 43. Review of the clinical record of resident #6 revealed a pnysician's order dated 3/1/03 for a CBC and SMA7 to be done on Monday (3/3/03) and a physician's order dated 3/3/03 for DSW 50 cc/hr X 3 days. Interview with staff revealed that the labs had not been drawn on 3/3/03 as ordered. 44. Interview with staff and observation in the medication room revealed that D5W 1000 cc, IV tubing and start kits were available. Further review of the clinical record revealed no documentation in the nurses' notes or Medication Administration Record of the hydration order. Labs drawn on 2/28/03 were documented as follows: Sodium 156 (reference range 135-149). Potassium 5.3 (reference range 3.5-5.3). BUN 37 (reference range 8-23). 45. A physician progress note dated 3/3/03 notes the labs and documents "azotemia - increase IVF." 46. Observation of the resident at 9:45 am on 3/4/03 revealed no IV infusing. Interview with the staff nurse revealed that she was unaware of the intravenous fluid order. Interview with the Director of Nursing at 10:45 am on 3/4/03 17 revealed that she was unaware of the IV hydration order. She Suggested that AHCA surveyors consult the 24-hour report, which noted that staff had been unable to start a peripheral line. The day staff nurse revealed that she had not been told of the need to start the IV in report. 47. At 12:15 pm on 3/4/03, the DON stated that she had started the IV with a peripheral line, 21 hours after the surveyor noted the order on the record. 48, Interview with staff and review of the phlebotomy log revealed a CBC and SMA7 were drawn on 3/4/03 in the morning, not 3/3/03 as ordered. Lab results were obtained from staff at 10:00 am on 3/5/03. The sodium level remained e-evated at 150, potassium was within normal limits at 4.1, and the BUN remained elevated at 28. 49, Review of the clinical record revealed a physician's order to increase gastrostomy tube flushes from 100 cc of water to 250 cc of water every 4 hours on 3/1/03. Review of the medication administration record of resident #6 on 3/5/03 revealed that the flushes were documented as done once during the 7 am-7 pm shift from 3/1-3/5/03 and once during the 7 pm-7 ar. shift from 3/1-3/4/03. RESIDENT #13 50. Resident #13 was observed on 3/3/03 at approximately 10:00 am and again at 2:00 pm to have a gastrostomy tube 18 feeding infusing at 50 cc/hr via a pump. A Dietary assessment dated 2/26/03 suggested an increase in rate to 60 cc/hr and an increase in flush to meet the resident's fluid needs. Review of the clinical record revealed a physician's order dated 2/26/03 for Nutrivent 60 cc/hr x 23 hours and to increase flushes to 150 cc water every 4 hours. Further review of the clinical record of resident #13 revealed a physician's order dated 2/28/03 for an increase in gastrostomy tube flush to 200 cc of water every 4 hours. Review of the medication administration record (MAR) of resident #6 on 3/5/03 revealed that there was no documentation of administration of the flushes on the March MAR. Interview with staff on 3/5/03 at 2:00 pm revealed that every four hour flushes should be documented on the MAR daily at 9 am, 1 pm, 5 pm, 9 pm, l am, & 5 am. 51. Based on the foregoing, Hallandale Rehabilitation Center Nursing violated 483.25(j), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statures, which imposes an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7)(b), Plorida Statutes. DISPLAY OF LICENSE 19 Pursuant to Section 400.25(7), Florida Statutes Hallandale Rehabilitation 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” 20 EXHIBIT “A” Conditional License License # SNF 11920961; Certificate No.: Effective date: 03/05/2003 Expiration date: 12/31/2002 21 10108 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Counts I, II and III. 2. Assess against Hallandale Rehabilitation Center an administrative fine of $7,500.00 for the three (3) Class II violations on Counts I, II and III for the violations cited above. 3. Assess against Hallandale Rehabilitation Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4, Assess costs related to the investigation and prosecution of this matter, if applicable. 5. 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 20.57, Florida Statutes (2002). 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 Clerk, 22 Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST 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. Alba M. J. fhe ay Assistant General Counsel Agency for Health Care Administration 8355 NW 53° Street Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration Manchester Building 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 23 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 Dennis Sarcauga, Administrator, Hallandale Rehabilitation Center, 2400 E. Hallandale Beach Blvd., Hallandale, Florida 33009; G.J.s. Holdings, Inc. 3370 N. W. 47 Terrace, Lauderdale, Lakes, Florida 33319; Garson L. Lambert, 3370 N. W. 47 Terrace, Lauderdale Lakes, Florida 33319 on this A3nday of May, 2003. Alba M. Rodrigue 24

Docket for Case No: 03-002565