STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 224 any ie As STATE OF FLORIDA AGENCY FOR HEALTH CARE o ADMINISTRATION, painlen4 * d Petitioner, AHCA NO. 2003003323” 03-2957. =. vs. 03-3321. C4 COQUINA KEY HEALTH CARE RENDITION NO.: AHCA-04-O/ ve -S-OLC CENTER, INC., d/b/a COQUINA KEY HEALTH & REHABILITATION CENTER, Respondent. FINAL ORDER Having reviewed the administrative complaint dated August 11, 2003, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Stipulation and Settlement Agreement with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: The attached Stipulation and Settlement Agreement (Ex. 2), is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. a ORDERED: 1. The attached Stipulation and Settlement Agreement is approved and adopted as part of this Final Order and the parties are directed to comply with the terms of the Stipulation and Settlement Agreement. DONE and ORDERED this —>/day of Z Date 4 _ _, 2004, in Tallahassee, Leon County, Florida. CL: eh beech ele - Mary Pat Moore, Interim Secretary — Agency for/Health Care Administration_: A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Donna H. Stinson, Esq. Broad and Cassel 215 S. Monroe Street, #400 Tallahassee, FL 32301 (U. S. Mail) Wayne D. Knight, Esq. Senior Attorney Agency for Health Care Administration 525 Mirror Lake Dr. N. #330L St. Petersburg, FL 33701 (Interoffice Mail) Elizabeth Dudek Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Bldg #1 Mail Stop Code #9 Tallahassee, Florida 32308 (Interoffice Mail) Wendy Adams Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) William H. Roberts Hearing Officer Agency for Health Care Administration 2727 Mahan Drive, Bldg #3 MS #3 Tallahassee, FL 32308 (Interoffice Mail) Judge Carolyn S. Holifield Division of Administrative Hearings The DeSoto Bldg 1230 Apalachee Parkway Tallahassee, FL 32399-3060 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the past a method designated, on this the /2 day of ADU cl , 2004. A artcah Spe bis/ fe Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 921-8177 EXHIBIT A tabbies’ STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, v. Case Nos. 03-2957 COQUINA KEY HEALTH CARE CENTER, INC., 03-3321 d/b/a COQUINA KEY HEALTH & REHABILITATION CENTER, Respondent. / STIPULATION AND SETTLEMENT AGREEMENT Petitioner, Agency for Health Care Administration (hereinafter the “Agency”) through their undersigned representatives, and Respondent, Coquina Key Health Care Center, Inc., d/b/a Coquina Key Health & Rehabilitation Center (hereinafter “Respondent” or “Coquina Key “) pursuant to Sec. 120 Florida Statutes (2003), each individually, a ‘party”, collectively as “parties,” hereby enter into this Stipulation and Settlement Agreement (“Agreement”) and agree as follows: WHEREAS, Coquina Key is a skilled nursing facility licensed pursuant to Chapter 400 Part II, Florida Statutes (2003) and Rule 59A-4, Florida Administrative Code, (2003) ; and WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Coquina Key pursuant to Chapter 400, Part II, Florida Statutes; and WHEREAS, the Agency served Coquina Key with an administrative complaint notifying Respondent of its intent to impose a Conditional license and an administrative fine of $2,500.00, due to a survey conducted on August 11, 2003 and; TLHA\HEALTH\76245.1 32535/0001 DMA dma 3/30/2004 WHEREAS, Coquina Key timely requested a formal administrative hearing in a Petition for Formal Administrative Hearing; and WHEREAS, the parties have agreed that a fair, efficient, and cost effective resolution of this dispute would avoid the expenditure of substantial sums to litigate the dispute; and WHEREAS, the parties have negotiated and agreed that the best interest of all the parties will be served by a settlement of this proceeding; NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows: 1. All recitals are true and correct and are expressly incorporated herein. 2. Both parties agree that the whereas clauses incorporated herein are binding findings of the parties. 3. Upon full execution of this Agreement, Coquina Key agrees to a withdrawal of its request for Formal Administrative Proceeding, agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled including, but not limited to, an informal proceeding under Subsection 120.57(2), a formal proceeding under Subsection 120.57(1), appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi-court (DOAH) of competent jurisdiction. Provided, however, that no agreement herein, shall be deemed a waiver by either party of its right to judicial enforcement of this stipulation. 4, AHCA hereby agrees that Tag F224 from the August 11, 2003 survey, as incorporated into Count I of the Administrative Complaint, will be reduced from a class II to a Class III deficiency. As a consequence of this reduction in the class rating of the deficiency, TLH1\HEALTH\76245.1 2535/0001 DMA dma 3/30/2004 AHCA hereby rescinds its intent to impose a conditional license and a $2500 fine against Coquina Key. 5. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in the Circuit Court in Leon County, Florida. 6. By executing this stipulation, Respondent does not admit the validity of the allegations raised in the Administrative Complaint referenced herein. By executing this Stipulation, the Agency asserts the validity of the allegations raised in the Administrative Complaint referenced herein, except to the extent that they have been modified by this Stipulation, including, without limitation, those modifications set forth in Paragraph 4 above. The Agency agrees that it will not impose any other penalty against Respondent as a result of the survey completed August 11, 2003, except as may be authorized by Chapter 400.121(1)(b), Florida Statutes. In the event that the Agency imposes a penalty under Chapter 400.121(1) (b), Florida Statutes, Respondent reserves the right to challenge that penalty and any deficiency from those surveys which is used to support that decision in an administrative proceeding. 7. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and dismissing the above-styled case. 8. Each party shall bear its own costs and attorney fees incurred in this case, including any incurred in the negotiation and preparation of this Agreement. 9. This Agreement shall become effective on the date upon which it is fully executed by all the parties. 10. | Coquina Key, for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the TLH1\HEALTH\76245.1 32535/0001 DMA dma 3/30/2004 Agency for Health Care Administration, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, by or on behalf of Coquina Key or related facilities. 11. The Agency for Health Care Administration, does hereby discharge Coquina Key, and its agents, representatives, and attorneys of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency’s actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, by or on behalf of the Agency for Health Care Administration, excepting actions referenced in paragraph six (6). 12. This Agreement is binding upon all parties herein and those identified in the aforementioned paragraph ten (10) of this Agreement. 13. The undersigned have read and understand this Agreement and have authority to bind their respective principals to it. 14. This Agreement contains the entire understandings and agreements of the parties. 15. | This Agreement supercedes any prior oral or written agreements between the parties. 16. This Agreement may not be amended except in writing. Any attempted assignment of this Agreement shall be void. The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement. TLH1\HEALTH\76245.1 32535/0001 OMA dma 3/30/2004 Elizabeth Dudek Donna Holshouser Stinson Deputy Secretary, Broad and Cassel Managed Care and 215 S. Monroe Street, Ste. 400 Health Quality Assurance Tallahassee, FL 32301 Agency for Health Care Administration ; DATED: 3/3i Jo Valda Clark Christian General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee FL 32308 DATED: Ly LEV lose! of 0OS 603 3,23 TLH1\HEALTH\76245.1 32535/0001 DMA dma 3/30/2004 43/31/2804 15:89 7275921448 AHCA GENERAL COUNSEL PAGE 62/18 — EXHIBIT STATE OF FLORIDA : ff AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003003323 vs. COQUINA KEY HEALTH CARE CENTER, INC., d/b/a COQUINA KEY HEALTH & REHABILITATION CENTER, Respondent. / eee ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against COQUINA KEY HEALTH CARE CENTER, INC., a/b/a COQUINA KEY HEALTH & REHABILITATION CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. Thia is an action to impose an administrative fine in the total amount of two thousand five hundred dollars ($2,500) pursuant to Sections 400.102(1) (a) and (d), 400.022(3), and 400.23(8) (b), Florida Statutes. 2. The Respondent was cited for the deficiencies set forth below as a result of an annual survey conducted on or about April 25, 2003. 93/31/2884 _ 15:09 7275521448 AHCA GENERAL COUNSEL PAGE JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes. 4. Venue lies in Pinellas County, Division of administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-106.207 F.A.C. PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes and Rules 59A-4, Florida Administrative Code. 6. Respondent is a nursing home located at 435 — 4an4 Avenue South, St. Petersburg, FL 33705. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter S9A-4, Florida Administrative Code. COUNT I RESPONDENT FAILED TO PROTECT RESIDENTS FROM ABUSE BY OTHER RESIDENTS. VIOLATING RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE, INCORPORATING BY REFERENCE 42 CFR 483.13 (c). CLASS II DEFICIENCY 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about April 25, 2003, an annual survey was conducted at Respondent’s facility. 93/18 93/31/2084 15:83 7275521448 AHCA GENERAL COUNSEL PAGE 9. Based on clinical record reviews, review of the abuse, neglect and exploitation policy and a family interview and staff interviews, the facility failed to provide protection to residents to prevent resident-to-resident intimidation by fear and physical abuse. This involved six sampled residents (#1, 4, 12, 16, 26 and 28). The findinga include: Resident #4 was admitted to the facility on 10/02/02 with a diagnosis of senile dementia with delusional features per the admission sheet. This resident was elderly and frail, which according to the admission minimum data set (MDS), dated 10/18/02, weighed 85 pounds. Nurse’s notes on 12/22/02 at 6:00 p.m. noted that the resident stated his/her roommate pushed him/her down onto the floor. The resident was found lying on the floor and there was facial right sided bruising with a one inch skin tear on cheek and a 1/2 inch skin tear under the right eyebrow and a reddened apot in the corner of the right eye. On 01/13/03 at 1:00 p.m., the nurse noted in the nurses notes that the resident was involved in an altercation with another resident, who injured this resident's hands bilaterally. The left hand was bruised, swollen and resident complained of pain and discomfort when she moved the left hand. X-rays showed a mild ulnar and dorsal angulation and a fracture of the proximal phalanx of the left small finger requiring splinting. On 01/23/03 4:15 p.m., nurse noted in nurses notes that upon entering the room the resident was found on the floor. When the resident was asked what happened, the resident stated that he/she was pushed by another resident. Resident #16 was admitted to the facility on 11/15/02 with major diagnoses of Schizo-affective type disorder, obsessive-compulsive disorder, late effect intracranial injury, seizure disorder, anxiety state, depression and organic brain syndrome. On admission the resident waa taking Clozapine 350 mg. (milligrams) at bedtime and Lorazepam 0.5 mg. three times a day, according to physician orders of that date. On 01/02/03, the resident was seen by his/her physician, who discontinued the Clozapine and started the resident on Risperdal 1 mg. at bedtime and requested a psychiatric consultation. The Psychiatrist saw 84/10 83/91/2084 15:83 7275521448 AHCA GENERAL COUNSEL PAGE 85/10 ‘a the resident on 01/03/03 and discontinued the Risperdal and started the resident on Zyprexa 15 mg. On 01/17/03 at 11:00 a.m., the nurses notes document that the resident was noted to be kicking another resident (resident #1) in the right foot. On 01/19/03 at 7:00 a.m., nurse’s notes noted that the resident was yelling and kicked at another resident this morning. The Psychiatrist note on 01/20/03 noted that the resident was tolerating the Zyprexa but obviously decompensating. Decompensating secondary to discontinuation of Clozapine. Zyprexa was increased to 20 mg. at bedtime and the resident was started on Depakote 250 mg- to be given twice a day. Nurses notes on 02/18/03 at 6:30 p-m., noted the resident was becoming angry with another resident who kept coming in his/her room. He/she pushed the resident out of his/her room, threw a shoe to the resident and slammed his/her room door. It was noted that the resident wag using foul language loudly in his/her room. On 02/26/03 the social worker notes documented the resident had had an altercation with the resident's guardian. On 03/12/03 at 6:30 a.m., the nurse’s notes documented that the resident was rummaging through the laboratory technician kit and the resident became angry when told to stop and took a swing at the technician and called the technician abusive names. The nurse noted that the resident is becoming increasingly more agitated. On 03/21/03, according to the Physician's Telephone Orders, the Zyprexa was increased to 30 mg. to be taken at bedtime and resident was started on Tofranil 25 mg. at bedtime. On 04/02/03 at 2:45 a.m., the nurse’s notes document that the resident was "playing guitar, singing very loudly, uging profanity and using racial slura, roommate very nervous and afraid and cannot sleep because of the noise." At 6:00 a.m. the nurse noted that resident continues to be verbally abusive to staff and imaginary person, and kicked a resident (#27) on the leg. An order for Haldol 5 mg to be given daily was received according to the 4/02/03 Nurse's Notes at 11:00 a.m. On 04/04/03 the Depakote was inereased to 250 mg. in the morning and 500 mg. in the afternoon per the 4/4/03 Physician's Telephone Orders. On 04/21/03 at 7:00 a.m, it is noted in the nurse's notes that the resident began yelling racial slurs in the hallway and using profanity, when at the nurse's station walked by resident #26, who was sitting quietly in his/her wheel chair, and began hitting the resident with both closed hands on top of the head several times and trying to turn the wheelchair over. Review of the weekly behavior charting for this resident revealed that his/her behavior had been continuously escalating from the week of 01/21/03 through 04/14/03. Review of the resident care plan dated 2/26/03, revealed “83/31/2084 15:83 7275521448 AHCA GENERAL COUNSEL PAGE @6/18 the aggressive/abusive behavior displayed by the resident had not been addressed on the plan of care. Interview with the psychiatrist and the Director of Nursing (DON), on 04/25/03 at 11:30 a.m., and record review, revealed the only intervention the resident received was pharmaceutical intervention. The DON stated there were no interventions that worked with this resident. Resident # 1 has had numerous injuries since being admitted on the secured unit that include references in the medical record of being slapped by another resident on August 10, 2002 according to a quarterly assesament for that month. On 1/17/03 at 11:00 a.m., resident was kicked in room 208 in the right foot by resident #16, per the Nurse's Notes of the 7 to 3 shift. On 4/15/03 at 2:30 p.m., the resident obtained a skin tear to posterior right hand when another resident was pushing the resident's wheelchair in resident room, according to the 2:30 p.m. Nurse's Note. Resident record revealed that the resident was constantly removed from the Do Drop Inn during the firet week of 2/03 (on "Weekly Behavior Charting Form") because other residents were pulling the resident #1's hair ox agitating resident. There was not a care plan that addressed resident interaction with other residents or behavioral issues with other residents. Interview with the resident healthcare proxy by phone on 4/25/03 at 11:45 a.m., revealed that a care plan meeting for this resident was held on 4/22/03 at the healthcare proxy request. The meeting was to discuss the numerous skin tears and other injuries that have occurred in the past 6 months. The healthcare proxy stated during the 4/22/03 meeting that the facility wanted the resident to move from the second floor to the third floor because the resident would not be in jeopardy of injury from other residents on the third floor. The healthcare proxy said the facility stated the 50 residents on the third floor are not as aggressive as the residents on the second floor and the resident would not be a victim. Record review of resident #12 revealed that on 3/26/03 according to the Nurse's Notes (no time given), the resident was involved in an altercation with resident #28 in the TV room and was pushed down and kicked by resident #28. Resident #12 was sent to the Emergency Room for evaluation and treatment of "abrasion on right side mid pback- pain evident left sub capital area". The resident returned from the hospital the same day, nurses notes for 03/27/03 at 2:00 a.m., revealed " Resident resting in bed, unable to move to side for this writer to assess bruise on back, grimaced and screamed very loudly." The nursing notes for resident #28 for 3/27/03, revealed that a CNA witnessed the altercation and that resident #28 +93/31/2084 15:83 7275521448 AHCA GENERAL COUNSEL PAGE kicked resident #12. Resident #12 had no history of aggressiveness. Resident #28 was Baker Acted on 3/28/03 by the treating psychiatrist per the Nurse's notes. Nurse's notes from 03/27/03 revealed, "Resident (#28) very vicious to (another) resident, redirected (other) resident out of room until resident (#28) was more calm". Review of the facility's "Handbook for Abuse, Neglect, and Exploitation”, dated 08/01, revealed that the facility defined abuse as "The non-accidental infliction of physical or psychological injury, sexual abuse, unreasonable confinement, intimidation or punishment upon a disabled adult or an elderly person by a relative, caregiver, or any other person, with resulting physical harm, pain, or mental anguish.” and defined physical abuse as including "hitting, slapping, pinching, dropping, and kicking." Further review of the abuse policy revealed a section for Identification of ‘At risk' patients which stated, " the center identifies patiente who may be more at risk for possible abuse, neglect, or exploitation because of behaviors or physical or mental conditions." The procedure is "to assess each patient to determine if behaviors or conditions are present which would put the patient at risk for possible abuse, neglect, or exploitation, including patients with a history of aggressive behaviors, who wander and enter other patient's rooms and who require heavy nursing care or are totally dependent." The policy states that the care plan team will develop strategies to care for at risk patients and to train all caregivers in appropriate intervention techniques by identifying individual risk factors and developing appropriate preventive and or protective measures. 10. Respondent was provided a mandated correction date of May 25, 2003. 11. The facility is in violation of Rule S9A-4.1288, incorporating by reference 42 CFR 483.13(c), which requires the facility to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. 12. The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of two 97/18 »93/31/ 2084 15:83 7275521446 AHCA GENERAL COUNSEL PAGE thousand five hundred dollars ($2,500) is authorized under Sections 400.022(3), 400.102(1) {a,d@), and 400.23 (8) (b), Florida Statutes (2002). CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of the Agency on Count I; B. Impose a fine of two thousand five hundred dollars ($2,500) for the violations cited in Count I, against the respondent as authorized under Sections 400.102(1) (a, @), 400.23(8) (b); c. Attorney’s fees and costs and; D. All other general and equitable relief allowed by law. NOTICE The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page) .- 98/18 8 3/31/2804 15:63 7275521448 AHCA GENERAL COUNSEL PAGE a All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. Respectfully submitted, Le Wayne/fZ. Knight, E aAHCA‘< Senior Attorney Fla. Bar No. 0136440 525 Mirror Lake Drive N, 330L St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy hereof has been furnished to Nigel G. Skyte, Administrator, Coquina Key Health & Rehabilitation Center, 435 42°27 avenue South, St. Petersburg, FL 33705, Return Receipt No. 7002 2030 0002 7109 5394, on August ath, 2003. 83/18 43/31/2004 15:89 7275521448 AHCA GENERAL COUNSEL Copies furnished to: Nigel G. Skyte, Administrator Coquina Key Health & Rehab Center 435 - 4277 Avenue South St. Petersburg, FL 33705 (U.S. Certified Mail) Corporation Service Company Registered Agent for Coquina Key Health & Rehab. Center 1201 Hays Street Tallahassee, FL 32301-2525 (U.S. Mail) Wayne D. Knight, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330L St. Petersburg, Florida 33701 PAGE 106/18

Docket for Case No: 03-002957