Lip. 38ST CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, orem 4 vs. AHCA NO: 2003004497 WASHINGTON COUNTY CONVALESCENT CENTER, Respondent. / a ADMINISTRATIVE COMPLAINT. COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint, against WASHINGTON COUNTY CONVALESCENT 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 DOLLARS ($2,500) pursuant to Sections 400.102(1)(a), 400.121(1), and 400.23(8)(b), Florida Statutes and Florida Administrative Code Rules 59A-4.106 and S9A-4.1288. 2) The Respondent was cited for the deficiency set forth below based upon a complaint survey conducted on or about June 19, 2003. JURISDICTION 3) The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part I, Florida Statutes. 4) Venue lies in Washington County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, and Florida Administrative Code Rule 28-106.207. Page 1 of 7 CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 PARTIES 5) AHCA is the enforcing authority with regard to nursing home licensure law pursuant to Chapter 400, Part IJ, Florida Statutes and Chapter 59A-4, Florida Administrative Code. 6) Respondent is a skilled nursing facility located at 879 Usery Road, Chipley, Florida 32428. The facility is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. Its license number is 1065096 effective through December 30, 2003. COUNTI THE FACILITY FAILED TO ENSURE THAT ONE OF TWENTY-FOUR SAMPLED RESIDENTS RECEIVED PROPER TREATMENT AND CARE FOR THE SPECIAL SERVICE OF TRACHEOSTOMY CARE, INCLUDING EMERGENCY INTERVENTIONS FOR ACCIDENTAL TRACHEAL EXTUBATION. FLA. ADMIN. CODE R. 59A-4.106 AND 59A-4,.1288 (INCORPORATING BY REFERENCE 42 CFR § 483.25(k)(4)), 400.102(1)(a), 400.121, and 400.23(8)(b), FLA CLASS I DEFICIENCY 7) AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein. 8) The facility failed to provide appropriate emergency interventions for accidental tracheal extubation per the facility’s understood practice for one of twenty-four sampled residents. 9) The findings include: a) Review of the clinical record for Resident 24 revealed nursing notes on April 21, 2003 at 4:45 a.m. recorded the nurse was called to the room by a Certified Nursing Assistant (CNA) with reports the resident had "coughed out" his/her tracheotomy (trach). b) Upon entering the room, the nurse, who was a Licensed Practical Nurse (LPN) and later identified as the senior nurse on that shift, found the trach on the floor. This LPN immediately notified the doctor and received orders to transfer the resident to the North West Florida Community Hospital for trach replacement. c) Interview with the Licensed Practical Nurse (LPN) on June 19, 2003 at approximately 9:10 a.m. found the doctor did not specify the mode of transfer to the facility. Continued interview and Page 2 of 7 d) ¢) g) h) CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 review of the nursing documentation in the record found the resident was transferred across the parking lot to the facility via wheelchair, accompanied by two CNAs, without any attempt to re- insert the trach, without oxygen, and without calling 911. According to an interview with the administrator on June 18, 2003, at approximately 4:25 p.m., the transfer of Resident 24 was not performed in accordance with the understood policy of the facility. During the interview of the Administrator on June 18, 2003 at approximately 4:25 p.m., he presented a letter dated August 8, 2002 that was signed by the Hospital Administrator and endorsed by the nursing home Administrator with instructions that transporting across the parking lot would be acceptable after calling 911 for emergency transport and the transport was unavailable. Continued interview with the Administrator, Risk Manager, Director of Nursing, and a Registered Nurse Day Supervisor on June 18, 2003 at approximately 4:25 p.m. found the understood practice for accidental tracheal extubation was dictated by the Lippincott Manual and included the following instructions: i) Keep an extra trach tube and obturator at bedside. ii) If tube is coughed out, then attempt to reinsert tube immediately to maintain the patent’s airway. Although this information from the Lippincott Manual was copied by the Day Supervisor and provided as the facility's policy on June 18, 2003, this information was not included in facility's policies and procedures until June 18, 2003. Interviews were conducted with four (4) Licensed Practical Nurses (LPNs) on June 18, 2003 throughout the day. Three of the four LPNs stated they had not received any tracheal re-insertion training, but did receive training on tracheal cleaning and care. On June 19, 2003 at 9:10 a.m., there was further interview with an LPN who was on duty on April 21, 2003. During this June 19 interview this LPN revealed the following: Page 3 of 7 CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 (1) She did not know of a facility policy related to procedures for re-insertion of the trach after accidental extubation; (2) She did not feel comfortable in re-inserting a trach as she had never received formal training for re-insertion of an entire trach, but only had training for cleaning and care of the trach. (3) The LPN also stated she did not feel comfortable with doing an emergency re-insertion as there was no Registered Nurse in the building. (4) The LPN was not aware that there was to be an obturator or extra trach kept at the head of the bed and to her knowledge there was not one in the room of the resident, (5) Although an extra trach was kept in the treatment cart, but she did not wait to get this, or attempt to re-insert, but rather sent the resident on to the hospital. (6) The LPN assessed Resident 24 to be in no distress at the time of the incident, although no vital signs were documented, as the resident was laughing and talking with the CNAs. (7) The LPN stated she did not send the resident with any oxygen and thought the CNAs were appropriate escorts for the resident. (8) She stated she was working with an Agency nurse and could not leave the nursing home to accompany the resident across the parking lot. j) However, upon arrival at the Hospital, the nursing care flow sheet dated April 21, 2003 at 5:00 i) )) a.m. documented Resident 24’s arrival with “gasping resp. (respirations) and was placed on a cardiac monitor with heart rate between 30’s and 50’s with resident's eyes rolling back.” Emergency Room Records from the Hospital stated the resident's physical condition continued to decline and at approximately 5:10 a.m. the doctor was notified, Cardiac Pulmonary Resuscitation (CPR) was initiated, Oxygen Saturations were “0”, and a blood pressure and pulse was un- obtainable. At approximately 5:15 a.m., the Emergency Room doctor attempted to replace the trach without success, trach site continued to bleed, a full code was called and emergency medications were administered without success. Code was terminated at 5:30 a.m. and the resident was pronounced dead by the physician. Page 4 of 7 CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 10) Based upon the foregoing, the Respondent violated Florida Administrative Code Rule 59A-4.106, which required the Respondent to adopt, implement, and maintain written policies and procedures governing all services provided in the facility, including nursing services. 11) The foregoing also constitutes a violation of Florida Administrative Code Rule 59A-4.1288, which incorporates by reference the requirements of 42 CFR § 483.25(k)(5S). 42 CFR § 483.25(k)(5) requires the Respondent to ensure that residents receive proper treatment and care for tracheostomy care, a special service. 12) The foregoing also constitutes an intentional or negligent act materially affecting the health or safety of residents of the facility as defined by § 400.102 (1)(a), Florida Statutes and is subject to a fine under § 400.121 Florida Statutes 13) The foregoing constitutes a Class II deficiency as defined by § 400.23(8)(b), Florida Statutes as follows: A class II deficiency is a deficiency that the agency determines 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 I] 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. 14) The above referenced violation constitutes the grounds for the imposed Class II deficiency and for which a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) is authorized under § 400.23(8), Florida Statutes. CLAIM FOR RELIEF WHEREFORE, AHCA requests this Court to order the following relief: A. Make factual and legal findings in favor of AHCA on Count I, Page 5 of 7 CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 B. Impose a fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) for the violation cited in Count I against the Respondent under Sections, 400.102(1)(a), 400.121(1), and 400.23(8)(b), Florida Statutes and Florida Administrative Code Rules 59A-4.106 and 59A-4.1288. NOTICE OF RIGHTS CONTINUES ON NEXT PAGE Page 6 of 7 CERTIFIED ARTICLE NUMBER 7001 0360 0003 3804 4827 NOTICE OF RIGHTS 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 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: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. & Respectfully submitted this ag” day of August , 2003. Joanna Daniels Assistant General Counsel FL Bar I.D. No. 0118321 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 CERTIFICATE OF SERVICE T HEREBY CERTIFY that a copy hereof has been furnished to: Administrator WASHINGTON COUNTY CONVALESCENT CENTER 879 Usery Road, Chipley, FL 32428 ia oe Return Receipt No. 7001 0360 0003 3804 4827, this Qa” day of August, 2003. ~ < ma Daniels t : Assistant General Counsel JD/ghm Page 7 of 7 COMPLETE THIS SECTION ON DELIVERY A. Signature Complete items 1, 2, and 3. Also compléte: item 4 if Restricted Delivery is desired.“ <: @ Print your name and address on the reverse so that we can return the card to you. ™ Attach this card to the back of the mailpiece, or on the front if space permits. , OD Agent [1] Addressee afta item 17 'D) Yes UgAShingtor County | 1. Article Addressed to: Admin ist rector ONo 3. Service Type Wcertiied Mail © Express Mail O Registered OC Retum Receipt for Merchandise O insured Mail (1 C.0.D. Copvrlescest Cenk $14 Userey Road Chie ley, F} 3ayag | 4. Restricted Delivery? (Extra Fee) O Yes 2. Article Number 427 ; (Transfer from service label) 7001 0360 0003 3804 4 cere ete an PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1035 2 +

Docket for Case No: 03-003851