STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003003322 vs. THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY d/b/a KISSIMMEE GOOD SAMARITAN HEALTH CARE CENTER, 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 THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY, d/b/a KISSIMMEE GOOD SAMARITAN HEALTH CARE CENTER, (hereinafter “Respondent”) and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of two thousand five hundred dollars ($2,500) pursuant to Sections 400.102(1) (a) and (d), and 400.23(8) (b), Florida Statutes (2002). 2. The Respondent was cited for the deficiencies set forth below as a result of an annual survey conducted on or about May 8, 2003. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2002). 4. Venue lies in Osceola County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes (2002), and Chapter 28-106.207, Florida Administrative Code (2002). PARTIES 5. AHCA, is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part II, Florida Statutes (2002) and Rules 59A-4, Florida Administrative Code (2002). 6. Respondent is a nursing home located at 1550 Aldersgate Drive, Kissimmee, FL 34746. The facility is licensed under Chapter 400, Part II, Florida Statutes (2002) and Chapter 59A-4, Florida Administrative Code (2002), having been issued license number 1267096. COUNT I RESPONDENT FAILED TO ENSURE THAT RESIDENTS RECEIVED THE NECESSARY CARE AND SERVICES TO PREVENT THE DEVELOPMENT OF PRESSURE SORES. 42 CFR 483.25(c) (2002), INCORPORATING BY REFERENCE Fla. Admin. Code R.59A-1.288 (2002) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8. On or about May 8, 2003, an annual survey was conducted at Respondent’s facility. 9. Based on observation, interview, and record review, the facility failed to adequately assess, monitor and modify interventions to treat a pressure ulcer for one of twenty-four sampled residents with a history of severe pressure ulcers, and at high risk for redeveloping wounds. (#6) Findings: Record review of resident #6 revealed that the resident was admitted to the facility on August 26, 1997 with diagnoses of paraplegia, decubitus ulcer, depressive disorder and urinary tract infection. The resident was observed in bed on May 5, 2003, at 10:30 A.M., in semi-reclining position. The resident was alert, smiling, unable to verbalize, but making audible sounds when spoken to. The Unit 3 nurse manager stated that the resident had a stage III acquired pressure ulcer in the left gluteal fold. Review of the clinical records revealed that the resident had a history of a long term pressure ulcer on the right gluteal fold and had to undergo surgery for a skin flap to the right ischium on March 21, 2002. The wound healed after the surgical procedure. On January 13, 2003, the resident developed a new Stage II pressure ulcer on the left gluteal area, measuring 6 cm. by 2 cm. with no depth. The wound was assessed, identified, treated and documented as healed on February 14, 2003. From March 5, 2003 — April 30, 2003, the weekly skin assessment flow sheet, which monitors pressure ulcers and skin conditions, revealed "zero" which means "no pressure ulcer." Nurses’ notes for April 24, 2003 noted that a new pressure ulcer was discovered at a stage II (size 3.5 cm. x 1.5 cm.) on the left gluteal fold. At no time was there any documentation identifying a stage I pressure ulcer or reddened area. Treatment was initiated on the Stage II, including RepliCare dressing, every three to five days and, as needed. The treatment record sheet documented that the RepliCare dressing was changed on April 26, 2003. On May 1, 2003, nurses’ notes revealed the pressure ulcer had developed into a stage III (8 cm. x 5.5 cm.) and a new form of treatment was implemented. Review of the 24 hour communication log of the 300 wing from April 17, 2003 to May 2, 2003, revealed that the new pressure area was not addressed in the nurses’ daily morning stand up meetings, to make staff aware of the recurrence of the pressure ulcer. Interview with the Unit Manager on May 8, 2003, at 11:00 A.M., indicated that the resident was having loose bowel movements frequently. Feces would seep through the dressing and staff failed to monitor closely when the dressing was soiled. No additional interventions were adjusted in the nursing care plan of the certified nursing assistant (CNA) care flow sheets related to the increased bowel movements. Observation of the resident on May 6, 2003, at 11:00 A.M., found the resident in bed while the nurse performed a dressing change. The pressure ulcer measured 9.5 centimeters (cm) in diameter with irregular edges, and length was 7.5 cm x 5.6 cm. When the wound was opened, a foul smell was noted. The wound edges were beefy- red and clean with a moderate amount of sero-sanguinous drainage. On the left side of the wound was observed black eschar, approximately 3 cm in diameter. Around it was whitish slough and the area was hard to the touch. When the dressing change was performed by the staff nurse, it was observed that the resident grimaced in pain, moaning, but unable to verbalize needs. Interview with the director of nursing (DON) on May 6, 2003, at 3:15 P.M, confirmed that documentation on April 23, 2003 and April 30, 2003 revealed a "zero" on the skin assessment sheet. She stated: "I cannot justify the documentation error." Further interview with the DON validated that facility policy regarding pressure ulcer would be: 1) staff nurse does weekly skin assessment, 2) unit manager does wound care management, and 3) CNA verbally communicates changes in skin condition to the nurse. On the Nursing Assistant Flow Sheet, the order to "observe skin with all care given, and report changes to nurse" was signed by the CNA’s for the month of April on three shifts, but there was no documentation in the interdisciplinary care notes regarding any skin condition changes observed, reported or relayed to the staff nurse. Further interview with facility staff on May 8, 2003, at 10:50 A.M., revealed that facility policy would dictate that the pressure ulcer wound be referred to the physical therapy (P.T.) department, when wound would be classified as a stage III so aggressive treatment would be started and would prevent further tissue damage. When the wound was documented at a stage III on May 1, 2003, the P.T director verified that P.T. was not informed. Interview with the physical therapist on May 8, 2003, at 11:15 A.M., confirmed that wound assessment was performed on May 7, 2003, when resident was referred to their service for treatment, after the wound was observed by the surveyor. The therapist further stated that, since the wound was at this stage, the wound would require both chemical and physical debridement and healing would be longer. Facility staff further stated that the attending physician had not seen or assessed the wound since it was identified April 24, 2003, and that the size had doubled to the present date. 10. The above actions or inactions are a violation of 42 Code of Federal Regulations 483.25(c) (2002), incorporating by reference Rule 59A-1.288, Florida Administrative Code (2002), which requires the facility to provide each resident 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. As it relates to pressure sores, based on the comprehensive assessment of a resident, the facility must ensure that: (1) a resident who enters the facility without pressure sores, does not develop pressure sores, unless the individual's clinical condition demonstrates that they were unavoidable and(2); a resident having pressure sores, receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 11. Pursuant to Section 400.23(8) (b), Florida Statutes (2002), the foregoing is a class II deficiency and as such, has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. A class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more Class I or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 12. Respondent was provided a mandated correction date of May 30, 2003. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an “isolated” Class II deficiency. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: a. Enter actual and legal findings in favor of AHCA; b. Impose a $2,500 civil penalty against Respondent; c. Assess costs related to the investigation and prosecution of this case pursuant to Section 400.121(10), Florida Statutes (2002); and d. Grant any other general and equitable relief as appropriate. NOTICE The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes (2002). Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election of Rights (one page). 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, Habuaadl).chrecy Katrina D. Lacy, LEC. AHCA - Senior Attorney Fla. Bar No. 0277400 525 Mirror Lake Drive North St. Petersburg, Florida 33701 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished via U.S. Certified Mail Return Receipt No. 7002 2030 0007 8499 6492 to CT Corporation System, Registered Agent for Kissimmee Good Samaritan Health Care Center, 1200 S. Pine island : St Road, Plantation, FL 33324 dated on August —, 2003. Aiilhtyasd - Katrina D. Lacy, Egquire Copies furnished to: CT Corporation System Registered Agent for Kissimmee Good Samaritan HCC 1200 S. Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Orin K. Eimers, Administrator Kissimmee Good Samaritan HCC 1550 Aldersgate Drive Kissimmee, FL 34746 (U.S. Mail) Katrina D. Lacy, Esquire Agency for Health Care Administration 525 Mirror Lake Drive North, Suite 330G St. Petersburg, Florida 33701

Docket for Case No: 03-003847