STATE OF FLORIDA i AGENCY FOR HEALTH CARE ADMINISTRATION - AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003005055 AHCA No.: 2003005054 Vv. Return Receipt Requested: 7000 1670 0011 4849 4866 ARBOR LIVING CENTERS OF 7000 1670 0011 4849 4873 FLORIDA, INC. d/b/a 7000 1670 0011 4849 4880 INTEGRATED HEALTH SERVICES OF FLORIDA AT LAKE WORTH, 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 Arbor Living Centers of Florida, Inc. d/b/a Integrated health Services of Florida at lake Worth (hereinafter “Integrated Health Services of Florida at Lake Worth”) pursuant to 28-1)96.111, 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 $5,000.00 pursuant to Section 400.23(8), Florida Statutes [AHCA No.: 2003005054]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No. 2003005055]. 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 Palm Beach 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. Integrated Health Services of Florida at Lake Worth is a skilled nursing facility located at 1201 12 Avenue South, Lake Worth, Florida 33460 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I INTEGRATED HEALTH SERVICES OF FLORIDA AT LAKE WORTH FAILED TO PREVENT DEVELOPMENT OF A PRESSURE SORE AND DID NOT RECEIVE NECESSARY TREATMENT TO PROMOTE HEALING TITLE 42 SECTION 483.25(c), 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 Integrated Health Services of Florida at Lake Worth participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. During the Re-certification survey conducted on 4/1/03 - 4/3/03 and based upon observation, record review and interviews, it was determined the facility failed to prevent a pressure sore from developing, and implement interventions to promote healing for one (# 8) of twenty-four sampled residents. The findings include the following. 10. Resident # 8 was admitted to the facility on 7-30-02 and readmitted to the facility on 3-20-03, after a hospitalization for Renal Failure and Gastroenteritis. The resident’s diagnoses included a history of Multi-Cerebral Vascular Accidents and Hemiplegia (paralysis of only one side of the body.) The resident was documented in the facility's Weight book as weighing 245 pounds on 3-24-03. The resident required extensive assist for bed mobility, transfer and ADLs due to the Hemiplegia and weight of 245 pounds per documentation on the initial nursing assessment, dated 3-20-03. 11. During the initial tour on 4-1-03 at 9:30 AM, the staff nurse touring with the surveyor reported the resident was free of any pressure sores. She stated the resident was transferred with 3-4 aides, and sometimes they used the Hoyer Lift. She reported the mechanical lift was occasionally used for transfer during the resident's previous admission to the facility. On 4-1-03 at 9:30 AM, the resident was observed sitting in bed at approximately 45 degrees, on a _ regular mattress, and feeding his/herself breakfast. It was noted during a dressing change observation period on 4-2-03 at 10:20 AM, done by the wound care nurse, the resident had 3 pressure sores, Stage III on the Left buttocks, a Stage IV on the Right Buttocks and a Stage III on the Coccyx. Prior to the dressing change the resident was noted on his/her back with the fead of the bed elevated approximately 30 degrees while the resident was watching television. 12. Record review documented on the Initial Nursing Assessment, dated 3-20-03, the resident had an "excoriated buttocks and an open area to the sacrum". The Braden Scale for predicting pressure sore risk scored 16 on 3-20-03. A score of 18 or below is considered a risk for skin breakdown. Nursing notes, dated 3-22-03 documented an open area found on coccyx 0.7 cm X 0.5cm, wound is pink and no drainage; and documented as a "New Stage II to coccyx." Review of the physician's orders document an order, dated 3-22-03, to cleanse Stage II on coccyx with Normal Saline and apply Duoderm Dressing; and change every 3 days and as needed. The treatment was done as ordered on 3-22- 03. Further review of the physician's orders documents an order, dated 3-25-03, to apply Lantiseptic Cream to the buttocks every shift. The nurse's notes, dated 3-25-03 at 8:3C AM, documented "Buttocks evaluated, found to be excoriated. Wound superficial with peeling skin surrounding. No drainage. No redness. Lantiseptic Cream.every shift." The next documentation noted regarding the pressure areas was dated 3-28-03 at 2:55 PM stating, "Open area continues to coccyx. Treatment done as ordered." The next physician's order that applied to treatment to the buttocks was dated 4-1-03, stating, "Discontinue Lantiseptic to sacrum. Apply Zinc Oxide Cream to buttocks excoriation and cover with large Island Dressing." The nursing notes, dated 4-1-03, describe the dressing change that was observed by the writer; and documented as "Discontinued Lantiseptic to sacrum and new order for Zinc Cream and cover with Island dressing. Excoriation to left and right buttocks and coccyx with redness." Orders were documented on 3-27-03 for Protein Powder, 2 scoops two times a day, Vitamin C, 500 mg daily, and Zinc Sulfate 220 mg daily and all were given as ordered from 3-27-03 to time of survey for wound healing. Meal consumption was documented as 50-100% at most meals, per nutrition notes, dated 3-27-03. The resident had a care plan dated 3-25-03 that documented, "Resident will not develop any skin breakdown as seen by staff each shift thru: (date left blank on care plan). The approach was to reposition every 2 hours; keep clean and dry; assist to bathroom before meals and at bedtime, encourage good intake of fluid/foods; skin observation during am/pm care treat /prevention as ordered by physician; and handwritten on the care plan was Lantiseptic to sacrum 3/22/03, and Zinc Oxides Cream to sacrum daily 4-1-03. The resident stated he/she was unable go to the bathroom, due to incontinence of bowel and bladder and ambulation problems from his/her strokes. The care plan was not revised as treatment orders changed, until after surveyor intervention on 4-1-03. The resident denied being repositioned every 2 hours, and admitted he/she desired to be up in the wheel chair most of the day. The resident was observed sitting in a wheelchair on 4-2-03 at 11:30 AM. The wheelchair seat did not have a gel cushion. Review of the Treatment Administration Record documented 9 blank spaces from 3-25-03 through 3-31-03, where nurses were _ to initial for following the treatment plan for the order of "Apply Lantiseptic Ointment to excoriated sacrum every shift.” 13. On 4-1-03 at 10:30 AM the wound care nurse was interviewed after the dressing change and about the staging of the three open areas. Her reply was that "the three areas were excoriated. They were not pressure areas. It was like peeling areas, until this morning." 14. Interview was conducted with the Interim Director of Nurses, on 4-1-03 at 11:45 AM. Policies and Procedures of Wound Care/Pressure Sores were requested. The facility's Policy states, "Pressure ulcers will be assessed end treated in accordance with generally accepted guidelines (e.g. Agency for Health Care Policy and Research). Consistent language and terminology will be used to stage and document all pressure ulcers. When documenting wound stage the following language should be utilized: Wound is a (healing/nonhealing) stage (1, 2, 3, 4) that currently has the visual characteristics of a stage (1, 2, 3, 4) wound.” 15. Further interview was conducted with the resident on 4-2-03 at 10:30 AM. He/she stated "They (the staff) don't change my diaper or clean my buttocks at night. I go all day without a diaper change, when I sit in the chair.” The resident stated he/she was incontinent of bladder and bowel. The resident reported he/she prefers to sit in the wheel chair, but the staff does not always use the Hoyer lift to transfer the resident. The wheelchair was observed to have a regular wheelchair seat on 4-1-03 and 4-2-03 at 10:30 AM. After intervention the resident was noted to have a low air-flow mattress on the bed, which was applied on 4-2-03 evening, and a gel cushion for the wheelchair seat, noted to be in use on 4-3-03 at 10:20 AM; as well as a Foley catheter inserted on 4-3-03 PM and connected to a drainage bag. 16. Based on the foregoing, Integrated Health Services of Florida at Lake Worth violated 483.25(c), 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 carries, in this case, an assessed fine of $5,000.00 (fine is doubled due to a previous class II citation). This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Integrated Health Services of Florida at Lake Wroth 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” EXHIBIT “A” Conditional License License # SNF 13010961; Certificate No.: Effective date: 04-03-2002 Expiration date: 09-30-2003 10361 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 Count I. 2. Assess against Integrated Health Services of Florida at Lake Worth an administrative fine of $5,000.00 for one (1) Class II violation as cited above. 3. Assess against Integrated Health Services of Florida at Lake Worth 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 120.57, 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, 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. Qutas tn. Be dase x 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 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 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 Barbara Yanez-Artiles, Administrator, Integrated Health Services of Florida at Lake Worth, 1201 12 Avenue South, Lake Worth, Florida 33460; Arbor Living Centers of Florida, Inc., 910 Ridgebrook Road, Sparks Glencoe, Maryland 21151; National Corporate Research, Ltd., Inc., 103 N. Meridian Street, Tallahassee, Florida 32301 on this Konolday of Onsouuate , 2003. Alba M. Ltn nsqQ 14,

Docket for Case No: 03-003863