STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO: 2003003585 vs. EMERALD OAKES HEALTH CARE ASSOCIATES, LLC, d/b/a MAGNOLIA HEALTH AND REHABILITATION 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 EMERALD OAKES HEALTH CARE ASSOCIATES, LLC, d/b/a MAGNOLIA HEALTH AND REHABILITATION 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 (da), 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 5- 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 Sarasota County, Division of Administrative Hearings, pursuant to Section 120.57 Florida Statutes, 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 1507 South Tuttle Avenue, Sarasota, FL 34239. The facility is licensed under Chapter 400, Part II, Florida Statutes (20020 and Chapter 59A-4, Florida Administrative Code (2002), having been issued license number 11420962. COUNT I RESPONDENT FAILED TO ENSURE THAT RESIDENTS RECEIVE ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS 42 CFR § 483.25(h) (2) (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 5-8, 2003, an annual survey was conducted at Respondent’s facility. 9. Based on interview, resident record review, review of adverse incidents and review of in-services, Respondent failed to ensure that one (Resident #7) of twenty-one active residents reviewed, received adequate supervision and assistance devices to prevent a fractured leg. Findings: 1. Interview with Resident #7 on May 6, 2003, revealed that the resident suffered a fracture of the right leg in November, 2002. The resident stated that he/she was transferred to a shower chair and when staff started to push the chair, his/her leg became entangled in the bar on the bottom of the shower chair. 2. Review of the medical record for Resident #7 revealed that the resident had a diagnosis of paraplegia. Further review revealed that the resident is coded on Minimum Data Set (MDS) as having no problem with long-term memory, and capable of making decisions consistently. Review of the nursing notes revealed that the facility was unable to produce nursing notes from November 1, 2002 to November 12, 2002. On May 9, 2003, at 4:30 P.M., the facility faxed the missing nursing notes to the surveyor, twenty-three hours after the surveyors had exited the building. Review of the nursing notes revealed a note dated November 12, 2002, at 6:30 A.M., indicating that the resident had a Foley catheter change done, and tolerated the procedure well. The next note, dated November 12, 2002, at 9 A.M., states, "Found purple/dark blue discoloration appears to be bruising to bilateral LE (lower extremities) below knees. Resident states when CNA (Certified Nursing Assistant) on Saturday got her OOB, (out of bed) she had the bruises. Resident recalls being transferred with Hoyer lift. No further injury noted at this time." The next note, dated November 12, 2002, at 9:30 A.M. states, "during transfer, resident was lowered to floor. The transferred from floor to shower chair times 4 assist (sic). No injury noted at this time." The next note on November 12, 2002, at 6 P.M., states, "resident complained of pain in right LE below knee on right LE, dark purple with swelling towards knee. Dr.---- called X-ray ordered." The next note on November 12, 2002, at 9 P.M., "---- X-ray arrived. X-ray taken. Resident continues to complain of severe pain. As needed pain medication given." The next note on November 12, 2002, at 10 P.M., "X-ray repeated due to misplacement of 1st films.” At 11:15 P.M., on November 12, 2002, the nurse notes, "--- called in report with positive fracture of Tibia below knee." The notes indicate the resident was transported to the hospital at 11:30 P.M. on November 12, 2002 and remained in the hospital until November 16, 2002. On December 9, 2002, the resident was discovered to have an impacted fracture to the left leg. The nursing notes prior to this date indicate the resident was getting out of bed with the use of the Hoyer lift. 3. Review of the adverse incidents with the Risk Manager on May 8, 2003, at 9 A.M., revealed the facility investigation included an interview with the CNA involved in the incident, and the resident. The CNA stated she had manually transferred the resident from the bed to the shower chair with the aid of the nurse on duty, when the resident's leg got twisted in the bar on the shower chair. The statement from the resident revealed the resident said she was transferred by the Hoyer lift. The Risk Manager was questioned about the discrepancies in the statements between the CNA and the resident, and his response was that the former Director of Nursing told him the resident did not like to use the Hoyer lift. He stated at this point he considered the incident adverse and did not do any further investigation; he did not speak to the nurse who helped the CNA with the transfer. The Risk Manager stated he was under the impression the fracture occurred during the transfer, he was not aware the resident states the fracture happened after the resident was placed in the shower chair and was being pushed toward the shower. 4. The Risk Manager stated when the facility considered the incident adverse, his plan for prevention of reoccurrence was a mandatory in-service for transfer using the Hoyer lift. He stated he did not think other in-services were needed. The in-service was done on December 13, 2002 at 8 A.M., 10 A.M. and 2 P.M.; 3 days after the resident suffered a second fracture of unknown origin. Review of the in-service outline and the sign-in sheet for staff who attended the in- service revealed eighteen CNA's attended. However, the facility employs more than eighteen CNAs. The CNA involved in the incident did not attend the in-service on the Hoyer lift. The Risk Manager was not aware the CNA did not attend the in-service or that all of the CNA’s had not attended the in-service. 10. The above actions or inactions are a violation of 42 Code of Federal Regulations 483.25 (h) (2) (2002), which requires the facility to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 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 June 8, 2003. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an “isolated” Class ITI 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, Katrina D. Lacy, Esqui AHCA — Senior Attorney’ Fla. Bar No. 0277400 525 Mirror Lake Drive North St. Petersburg, Florida 33701 Kalkirwd. Meta CERTIFICATE OF SERVICE —_— eee RN EE 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 6508 to cT Corporation System, Registered Agent for Kissimmee Good Samaritan Health Care Center, 1200 S. Pine Island Road, Plantation, FL 33324 dated on August 197 2003, Duar - he Katrina D. Lacy, Esq 6 Copies furnished to: CT Corporation System Registered Agent for Magnolia Health & Rehab Ctr 1200 S. Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Linda F. Howard, Administrator Magnolia Health & Rehab Center 1507 S. Tuttle Avenue Sarasota, FL 34239 (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: 03-003869