Petitioner: DESOTO HEALTH & REHABILITATION, LLC, D/B/A DESOTO HEALTH AND REHABILITATION
Respondent: AGENCY FOR HEALTH CARE ADMINISTRATION
Judges: LAWRENCE P. STEVENSON
Agency: Agency for Health Care Administration
Locations: Arcadia, Florida
Filed: Oct. 29, 2003
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Tuesday, December 2, 2003.
Latest Update: Dec. 25, 2024
FILED
STATE OF FLORIDA PEC 30 03
AGENCY FOR HEALTH CARE ADMINISTRATION "
HCA
DEPARTMENT CLERK
STATE OF FLORIDA
AGENCY FOR HEALTH CARE
ADMINISTRATION,
Petitioner, LDs- Desed
v. AHCA NO. 2003001959 / 03: 53339
2003006976 / 03-4011
DESOTO HEALTH AND REHABILITATION, ;
L.L.C., d/b/a DESOTO HEALTH AND RENDITION NO.: AHCA-03- ‘1&-S-OLC
REHABILITATION
Respondent.
ee ——SS
FINAL ORDER
Having reviewed the administrative complaint dated July 17, 2003 and
the Notice of Intent to Deny dated September 25, 2003, attached hereto and
incorporated herein (Ex. 1 & 1a), 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.
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.
2. DeSoto Health & Rehabilitation shall Participate in a six - month
survey cycle commencing from March 2003.
3. DeSoto Health & Rehabilitation shall pay the Agency $3,000.00
in survey fees, to be paid at the completion of the next survey occurring
after the execution of this settlement agreement.
4, DeSoto Health & Rehabilitation shall withdraw its Petition for
Formal Hearing.
5. The Agency shall withdraw its revocation of license and denial of
DeSoto Health & Rehabilitation’s licensure renewal.
DONE and ORDERED this © day of Lec en beer , 2003,
in Tallahassee, Leon County, Florida.
VR Pud ely
edows, MD, Secretary
]
ealth Care Administrat
Rhonda M.
Agency for
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:
Jonathan S. Grout, Esquire
Goldsmith, Grout & Lewis, P.A.
2180 Park Avenue North, #100
Post Office Box 2011
Winter Park, FL 32790-2011
(U. S. Mail)
Eileen O’Hara Garcia
Senior Attorney
Agency for Health Care Administration
525 Mirror Lake Dr. N. #330D
St. Petersburg, FL 33701
(Interoffice Mail)
Jean Lombardi
Finance & Accounting
Agency for Health Care Administration
2727 Mahan Drive MS#14
Tallahassee, FL 32308
(Interoffice Mail)
Elizabeth Dudek
Deputy Secretary
Agency for Health Care Administration
2727 Mahan Drive Bldg#1, MS#9
Tallahassee, FL 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
Informal Hearing Officer
Agency for Health Care Administration
2727 Mahan Drive, Bldg #3, MS#3
Tallahassee, FL 32308
(Interoffice Mail)
T. Kent Wetherell, II
Administrative Law Judge
Division of Administrative Hearings
The DeSoto Building
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
method designated, on this the &O day of DeLee , 2003.
ye ary mcChaken Meeecy Cell
Agency for Health Care Administration
2727 Mahan Drive, Building #3
Tallahassee, Florida 32308-5403
(850) 921-8177
STATE OF FLORIDA
AGENCY FOR HEALTH CARE ADMINISTRATION
STATE OF FLORIDA, AGENCY FOR
HEALTH CARE ADMINISTRATION,
Petitioner,
vs. AHCA NO: 2003001959
DESOTO HEALTH & REHABILITATION, L.L.c.,
DESOTO HEALTH AND REHABILITATION
Respondent.
ADMINISTRATIVE COMPLAINT
EME EVE COMPLAINT
COMES NOW the Agency for Health Care Administration (hereinafter
“AHCA”), by and through the undersigned counsel, and files this
Administrative Complaint, against DESOTO HEALTH & REHABILITATION,
L.L.C., d/b/a DESOTO HEALTH AND REHABILITATION (hereinafter
"Respondent") and alleges:
NATURE OF THE ACTION
1. This is an action to revoke the license of the Respondent
Pursuant to Section 400.121(1) and (3) (d), Florida Statutes.
2. The Respondent was cited for the deficiencies set forth
below as a result of surveys conducted on or about March 4, 2002 and
March 6-7, 2003.
JURISDICTION
3. The Agency has jurisdiction over the Respondent pursuant to
Chapter 400, Part II, Florida Statutes.
EXHIBIT
SP RO:
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4, Venue lies in Desoto County, Division of Administrative
Hearings, pursuant to Section 120.57 Florida Statutes, and Chapter 28-
106.207 Florida Administrative Code.
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 1002 North Brevard
Avenue, Arcadia, Florida 34266. The facility is licensed under
Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida
Administrative Code.
COUNT I
RESPONDENT DEMONSTRATED CONFIRMED PAST NON-COMPLIANCE FROM THE DATES
OF 2/1/03 THROUGH 2/7/03 VIOLATING Fl. Admin. Code R.59A-4.1288
INCORPORATING BY REFERENCE 42 CFR 483.13 (c) and 483.25 (m)
CLASS I DEFICIENCY
7. AHCA re-alleges and incorporates (1) through (6) as if
fully set forth herein.
8. A Complaint survey was conducted on or about March 06-07,
2003.
9, On that date, based on staff and resident interviews,
clinical records and investigation reports it was determined the
facility failed to provide goods and services necessary to avoid
physical harm, mental anguish, or mental illness for 1 (Resident #1)
of 5 residents.
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10. Tag F224 Requirement:
S/S J Resident Behavior and Facility Practices.
The facility must develop and implement written polices and Procedures
that prohibit mistreatment, neglect, and abuse of residents and
misappropriation of resident property.
ll. This requirement was not met as evidenced by:
a. On 3/4/03 at 2:15 P.M., during a phone interview the
complainant stated, "Dr. had told her she was to get two
injections a day to prevent problems with her legs. I was
transferred to DeSoto Health and Rehab after attempts were made
with two other facilities that had no beds. I arrived at DeSoto
at 8 P.M. on Saturday 2/1/03 and was there Sunday, Monday and
Tuesday Morning. All this time I did not get any of my
medications. The facility nurse also took my inhalers (which I
brought with me) away and did not give them back to me until
discharge. I did not see a doctor and I had made arrangements to
be transported to (nursing home) in (town) ."
b. According to interview with the Licensed Practical
Nurse (LPN) conducted on 3/6/03 at 2:50 P.M., the complainant was
admitted to DeSoto Health and Rehab on 2/1/03 at 8:00 P.M. This
LPN had never done an admission before. This LPN also stated she
had called the Registered Nurse Supervisor (RNS) six times to
make sure she was doing the admission process correctly.
However, the Supervisor states, "I don't recall talking to her
(LPN) about an admission."
(
c. However, the resident was admitted with a diagnosis of
Status/Post Left Knee Replacement, Diabetes, Asthma and Angina.
Her orders read:
Physical Therapy (P.T.) daily BID (twice a day).
Full Code Status.
Keep incision clean/dry.
Remove black sutures 2/2/03.
Follow up with Dr. on 2/10/03 or 2/12/03.
1800 Calorie ADA (Diabetic) Diet.
Her Meds: Peri-colace 1 capsule P.O. (by mouth) QD (every day)
(stool softener)
Cetirizine 10 mg. P.O. Q.D. (for allergies) .
Terbutaline 2.5 mg. P.O. TID (three times a day) (anti-fungal
agent).
Montelukast 10 mg. P.O. Q.H.S. (every hours sleep).
Simvastatin 20 mg. P.O. Q.H.S. (lowers Cholesterol).
Acetaminophen 650 mg. P.O. Q 4 H PRN (as necessary) pain or temp.
>101.
NuIron 150 mg. P.O. Q.D. (anemia).
Triazolam 0.125 mg. P.O. Q.H.S. (for sleep).
Oxycodone 5 mg./APAP 325 mg. Q 4 H PRN 1-2 tabs for moderate
pain.
Enoxaparin 30 mg. Injection Q 12 H (Clot Prevention) .
Begin Ecotrin 1 P.O. when Levonix is D/ced (discontinued) .
Advair 100/50 1 inhalation B.I.D. with Combivent (Asthma Med.).
( (
Prevacid 30 mg. P.o. Q.D. (Gastric Secretion Inhibitor) .
Prednisone 20 mg. P.o. daily x (times) i week (Respiratory
Diseases) .
d. On 3/6/03 at 2:50 P.M., in an interview with the LPN
who admitted the resident, Stated, "I faxed the med order to Med
Choice at about 8:30 P.M. or 9:00 P.M, f knew Eckerd's supplied
medications but they were closed. I forgot we were supposed to
Call the courier,"
e. The facility policy with Med Choice Pharmacy reads,
"Providing routine and timely pharmacy service seven days per
week and emergency pharmacy service 24 hourg a day, seven days a
week."
f£. On the pharmacy hours and delivery schedule the weekend
delivery schedule reads, Saturday - one delivery - leaves
pharmacy at 4:00 P.M. (please fax orders by 3 P.M.), After
regular business hours, a Pharmacist is always on call. Simply
call the pharmacy and speak with the pharmacy emergency service
operator. If you have an emergency, the operator will page a
Pharmacist to return your call.
12. Clinical record review revealed:
a. On 2/2/03 at 1430 in the nurses notes it states,
"Resident c/o (chief complaint) pain in legs. Tylenol 2 P.O.
given with some effect. She has been asking for her medications
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of breath). Up and 00B (out of bed) in w/e (wheelchair) for
short period to make a Phone call. She's alert and oriented.
Had black sutures removed today." This note is signed by a RN.
b. The 3-11 Summary for 2/2/03 states, "Resident given
Neb. Tx. Albuterol. Tylenol 2 at 5:30 P.M. for left knee pain.
P.T. taken in room. Resident unhappy about unavailability of
meds. Reassured meds will be coming this P.M." These notes were
also signed by a different RN.
Cc. The nurses notes for 11-7 on 2/3/03 at 0205 A.M. State,
"Resident has been awake this shift, upset about medications.
Given Tylenol 2 tabs for headache at 0130 A.M. Also requested
Neb Tx. for difficulty breathing. Reassured her meds were
ordered."
d. At 1500 on 2/3/03, the nurses notes read, "Resident is
angry for not having her meds in the facility. She made
arrangements to be transported to Wauchula nursing home."
e. At 1620 on 2/3/03, the facility doctor wrote an
admission note stating all her diagnosis and her meds. No
mention was made about the resident not receiving her
medications.
£. At 0130 on 2/4/03, resident was given Percocet for pain
to left leg. Her medication had been delivered Monday evening at
around 11:00 P.M.
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g. There is conflicting information noted on the MAR
(Medication Administration Record), so it is hard to determine if
this resident received Percocet on 2/2/03 and 2/4/03. During the
phone conversation with the complainant it was learned that the
nurses stated they were borrowing meds from another resident for
her.
h. On 2/7/03, the DON had given an in-service on not
accepting admissions without a completed 3008.
i. At 0750 on 2/4/03, resident was discharged to
Nursing Home.
j. It was learned during a conference with Adult
Protective Services that Ace Medical was taking the resident to
Nursing Home when they received a phone call that a bed
was available at Hospital Transitional Care Unit. So they
turned around and took the resident there because that is where
she originally wanted to go.
k. At 0900 A.M. on 2/4/03, she was admitted to
Hospital. The nurses notes read, has deep cough, has wheezes,
4+ edema to both legs. She came from DeSoto Memorial (Rehab) and
was in need of transfer.
1. According to the admission note (from the doctor) dated
2/4/03, the patient initially went toa nursing home after the
initial post-op period and apparently, "she had a poor situation
there." She wasn't provided with the adequate treatment that she
needed. The patient has left knee pain and she has become short
i i
of breath associated with bilateral leg swelling and not doing
very well. The plan by the physician indicates Hospitalized in
the Transitional Care Unit with evaluation by P.T. and 0.7.
(Occupational Therapy). The Patient will be on bed rest today
after she stabilizes. She will be on intravenous Lasix. Heparin
lock will be inserted and we will obtain blood work today
including the Troponin-I, BNP, and Chemistry panels. [I will
follow the patient. Pertinent orders are written in the chart.
She will be on ace inhibitors, nitrates, and calcium channel-
blockers for aortic insufficiency. She will also be on Combivent
and Advair to take care of the Chronic Obstructive Pulmonary
Disease component and continue on Zocor and Singular. Patient
appears to be a good candidate for rehab but we will limit the
rehab at this point in time until we feel that volume over-load
is controlled.
m. On 3/6/03, in an interview with the DON (Director of
Nursing) she stated, "We (the facility) did not know about this
incident until you (the surveyor) walked in today." However, on
2/7/03 the DON had given an in-service on not accepting
admissions without a completed 3008 (Transfer Form) .
n. Interviews with the four nurses that had cared for this
resident indicated all knew the proper steps to take to get
medications on a weekend. The LPN stated, "We faxed the med
sheet at night and there is no delivery on Sunday so the day
shift should have called the pharmacy." An RN stated, "It was my
RAS evens ereeenaneeee sntirns
f .
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1st or 2° night working and I noticed they (meds) weren't in but
figured they were ordered and should be here by 11:00 P.M. and
the night nurse would give them."
13. On 3/6/03, during this complaint investigation all staff
interviewed knew the Proper procedure for ordering medications and 4
new admission charts were reviewed (none were admitted on a weekend)
and all their medications were ordered and given as ordered.
14. The DON stated she would have to counsel the involved
employees and possible Suspension. Then she would in-service all
nurses.
15. Tag F333 Requirement:
Medication Errors. The facility must ensure that residents are free
of any significant medication errors.
16. Based on clinical record review, staff and resident
interviews the facility failed to administer medication for 1
(Resident #1) of 5 residents, which caused the resident discomfort and
jeopardized her health and safety. This occurred during a period of
eight shifts and involved five different nurses.
17. This is evidenced by:
a. On 2/1/03, resident was admitted to DeSoto Health and
Rehab with diagnosis of status/post left knee replacement,
Chronie Obstructive Pulmonary Disease, Diabetes, Asthma, and
History of Angina.
eam hae:
re cece
;
Her Meds: Peri-colace 1 capsule P.O. (by mouth) oD (every day)
(stool softener) .
Cetirizine 10 mg. P.O. Q.D. (for allergies).
Terbutaline 2.5 mg. P.O. TID (three times a day) (anti-fungal
agent).
Montelukast 10 mg. P.O. Q. H.S. (every hours sleep).
Simvastatin 20 mg. P.O. Q.H.S. (lowers Cholesterol).
Acetaminophen 650 mg. P.O. Q 4 H PRN (as necessary) pain or temp.
>101.
NuIron 150 mg. P.O. Q.D. (anemia).
Triazolam 0.125 mg. P.O. Q.H.S. (for sleep).
Oxycodone 5 mg./APAP 325 mg. Q 4 H PRN 1-2 tabs for moderate
pain.
Enoxaparin (Levonix) 30 mg. Injection Q 12H (Clot Prevention) .
Begin Ecotrin 1 P.O. when Levonix is D/cd (discontinued) .
Advair 100/50 1 inhalation B.I.D. with Combivent (Asthma Med.).
Prevacid 30 mg. P.O. Q.D. (Gastric Secretion Inhibitor).
Prednisone 20 mg. P.O. daily x (times) 1 week (Respiratory
Diseases) .
b. On 3/6/03 at 2:50 P.M., in an interview with the LPN
who admitted the resident, stated, "I faxed the med order to Med
Choice at about 8:30 P.M. or 9:00 P.M. I knew Eckerd's supplied
medications but they were closed. 1 forgot we were supposed to
call the courier."
RR enna A TN,
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Cc. In an interview with the DON on 3/6/03 at 1:00 P.M., it
was discovered that the initials on the MAR with a circle around
them means they were not given.
d. The MAR showed that Peri-colace 1 capsule,
Acetaminophen 650 mg., and Oxycodone 5mg/325 mg. APAP were the
only meds given on 2/2/02.
e. On 3/4/03, during an interview with the resident it was
learned that the nurses had told her they were borrowing meds for
her from their EDK (Emergency Drug Kit) and other residents.
f. On 2/3/03, the MAR showed that only Acetaminophen 650
mg., Peri-colace 1 capsule, and Montelukast 10 mg. were given.
g. On 2/4/03, Peri-colace 1 capsule, Claritin 10 mg.,
Terbutaline 2.5 mg, Combivent Inhaler 2 puffs, Advair 100/50 1
inhalation, Prednisone 10 mg., and Oxycodone 5 mg/325 mg. APAP
and Lovenox 30 mg. SQ injection were the only meds given.
h. The MAR clearly shows on 2/2/03, 2/3/03 and 2/4/03 the
resident did not receive all her ordered medications. This error
was not noticed on eight consecutive shifts by five different
nurses caring for this resident.
i. According to nurses notes dated 2/2/03 and 2/3/03 the
resident did receive Nebulizer treatments of Albuterol for which
no written order could be found.
j. On 2/4/03, this resident was admitted to
Hospital TCU (Transitional Care Unit) with a diagnosis of fluid
over-load. On admission the resident's weight 211 lbs, was short
11
of breath, has significant leg swelling associated with some
tachycardia and uncontrolled blood pressure. She received
intravenous Lasix therapy and on 2/5/03 weighed 206 lbs.
k. The deficient practice was corrected on 2/7/03.
18. The above actions or inactions constitute a violation of (1)
Chapter 59A-4.1288 Fl. Admin. Code. R. 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. (2)
Chapter 42 CFR 483.25(m) which requires the facility to ensure that it
is free of medication error rates of five percent or greater; and
residents are free of any significant medication errors.
19. The above referenced violations constitute the grounds for
the one (1) imposed Class I deficiency.
COUNT ITI
RESPONDENT WAS CITED FOR TWO CLASS I DEFICIENCIES ARISING FROM
SEPARATE SURVEYS OR INVESTIGATIONS BETWEEN SEPTEMBER 2000 AND MARCH
2003 (30 MONTH TIME PERIOD) VIOLATING §400.121(3) (ad) Fl. Stat. (2002)
CLASS I DEFICIENCY
20. AHCA re-alleges and incorporates (1) through (6) as if
fully set forth herein.
21. A Health Licensure and Certification survey was conducted on
or about March 04-08, 2002.
22. Tag 325 Requirement:
23. On that date, based on observations, clinical record review,
and interview with the facility's consultant RD (Registered
12
(
Dietician), MDS (Minimum Data Set) Coordinator, Director of Nursing
(DON) and facility nursing staff, the facility failed to provide
adequate nutrition resulting in significant weight loss for 1 of 13
active sampled residents (Resident #27).
24. This is evidenced by:
1. Resident #27, who receives all hydration and nutrition
via Gastrostomy Tube, being admitted to the hospital with
Sepsis from a UTI (Urinary Tract Infection) and severe
dehydration as evidenced by abnormal lab results including
elevated WBC (White Blood Count), sodium, BUN (Blood Urea
Nitrogen) and Creatinine and an Albumin of 2.4 which is
indicative moderate protein depletion.
2. Calculation of the resident's BMI (Body Mass Index) of
18 that is indicative of being severely underweight. Normal
is 19 ~ 27.
3. Lack of intervention to correct inadequate amount of
calories by Gastrostomy tube being administered until
surveyor intervention.
4. Failure of RD evaluating and assessing resident within
72 hours of admission as outlined in the facility's Policy
and Procedures.
5. Administering incorrect tube feeding by not following
physician orders.
13
25.
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6. Incorrect assessment of RD evidenced by calculating
incorrect tube feeding contents and not following physician
orders for the correct formila to be given.
7. Evidence of a 6.8-pound weight loss (9.3%) in 16 days.
8. Incomplete documentation on the MAR (Medication
Administration Record) of amount of fluids and tube feedings
given prior to admission to the hospital and after re-
admission to the facility on 2/28/02.
9. Incomplete monitoring for fluid administration for
residents on tube feedings per facility protocol.
10. Failure to develop and implement a plan of care for
tube-feeding maintenance as indicated by RAP (Resident
Assessment Protocol) on 11/22/01. Due to inaccurate amounts
of calories given to this resident, lack of planning for
this resident's care, pre and post hospital stay, and in
light of the fact this resident is dependent on staff for
nutrition and hydration, the facility failed to maintain the
nutritional parameters necessary to prevent significant
weight loss for Resident #27.
The findings include:
a. Resident #27 was re-admitted to the facility on 2/28/02,
following a 9-day hospital stay. The resident has a history of
CVA (Cerebral Vascular Accident), Dysphagia with Gastrostomy tube
placement for nutrition and hydration, Aphasia Hypertension, and
Seizures. The resident also returned with a Stage II pressure
14
sore to the right lateral ankle and a Stage I pressure sore to
the coccyx.
b. Clinical record review revealed that a late entry was
written on 2/19/02 at 3:15 P.M., by facility nursing staff. The
entry reads, "...Unresponsive, cold and clammy, temp taken 101.7
ax (Axillary ~ meaning under the arm pit - clinical significance,
one must add one degree Fahrenheit to equal an oral temperature) .
ARNP (Advanced Registered Nurse Practitioner) in to see resid
(Resident) and rec'd order to send to E.R. (Emergency Room) for
eval. (Evaluation). ... Approx (Approximate) time of exit of
facility with 911 is 1:45 P.M." Emergency room records were
requested and received from the facility. Review of the E.R.
records reveal that the resident was admitted to the hospital
with the diagnosis of Septic Shock, Dehydration, Pneumonia and
Urosepsis.
c. The resident's History and Physical written by the
attending physician on 2/19/02 reads, "The patient is a 74 - year
old --- very well known to me, ...total care in the nursing home,
was seen by my nurse practitioner this afternoon and found to be
febrile with noisy breathing and respiratory distress. 'His/her'
urine color had become extremely dark and she transferred
"him/her' to the emergency room where 'he/she' was evaluated and
found to have evidence of elevated WBC count, infiltrate in the
right lower lobe, and severely hypotensive. 'He/she' was fluid
resuscitated and diagnosed as septic shock, stabilized in the
15
( (
Emergency Room and transferred to the floor for continued care."
The note continues, "GENERAL: The patient is conscious, barely
responsive, barely opening 'his/her' eyes to command, but does
not seem to be in acute distress. VITAL SIGNS: 99.5, 64
regular, 24, 102/50 now. Height 5'10, weight 113 lb 4 oz.
--- ASSESSMENT: 1. Pneumonia. 2. Urinary Tract Infection with
sepsis 3. Cerebrovascular Accident with hemiparesis and
contractures on the right."
da. The first available laboratory work-up is dated on
2/20/02 and was on the resident's facility clinical record.
WBC = 40.7 H - Reference range of normal = 4.8 - 10.8 thou/ulL.
BUN = 74 H - Reference range of normal = 8 - 23.0 mg/dL.
Creatinine 1.6 H - Reference range of normal = 0.8 - 1.5 mg/dL.
Sodium = 168 H - Reference range of normal = 137 - 145 mmoi/1.
Potassium = 3.0 L - Reference range of normal = 3.5 - 5.1
mmol/l.
Chloride = 128 H - Reference range of normal = 95 - 108 mmo1/1.
Total Protein = 5.7 L - Reference Range of normal = 6.3 - 8.2
g/dl.
Albumin = 2.4 L - Reference range of normal = 3.2
5.0 g/dl.
e. Review of the nurses' notes prior to 2/19/02, does not
indicate that the resident had refused any tube feeding or water
flushes. The only documented incidences of the resident pulling
apart the connection of the Gastrostomy tube from the pump was
noted on 1/23/02 and 1/31/02.
16
f. Prior to the resident's admission to the hospital on
2/19/02, the resident was receiving NutriVent 42 ec/hr via pump
with 200 cc of flush per shift and 50 cc of water before and
after medications. The resident was receiving medications at
6:00 A.M., 2:00 P.M., 9:00 P.M. and 10:00 P.M. This would equal
1000 cc per day of free water plus 787 cc of fluid from the tube
feeding and 1,512 K/cal in a 24-hour period. This order was
written on 2/5/02.
g. The resident's weight on 1/1/02 was 120 pounds. on
2/2/02, the residents weight increased to 122 pounds.
h. Review of the History and Physical dictated by the
attending physician on 2/19/02, in the hospital has a recorded
weight of 113.4. This is a 9.3% weight loss in 17 days.
i. Review of the resident's MAR reveals blank spaces of
documentation for tube feeding per pump on 2/10/02 and 2/13/02.
j- The facility's Policy and Procedure entitled - SPECIAL
NEEDS: ENTERAL FEEDINGS - reads, "9. Enteral feeding intake is
recorded on the Enteral Feeding guide and incorporated into the
clinical record on the shift/24 hour Intake totals of the Intake
and Output monitoring sheet in the record."
k. The surveyor requested all copies of the Intake and
Output monitoring sheets for Resident #27. Even though the
resident had been on Gastrostomy tube feedings since 10/4/01, the
only records that could be found start on 1/15/02.
17
1. Review of the Intake and Output sheets reveal the
documentation to be incomplete. Indeed, since the new order for
tube feeding and fluids was ordered on 2/5/02, there are no
shifts that are complete in documentation of Intake and Output.
In fact, all documentation of Intake and Output cease on 2/10/02.
m. Review of the physician's discharge summary from the
hospital for Resident #27, dated 2/28/02 reads: "Course and
Progress: ...Since patient was getting continuous infusion, and
apparently there has not been proper monitoring, I decided to
place the patient on bolus feeds with water supplements."
n. On 3/5/02 at approximately 8:00 A.M., the surveyor
observed the facility staff nurse administer the tube feeding.
The nurse aspirated for residual but did not check the
Gastrostomy tube for placement. The nurse then administered 30
cc of water; one can of Choice DM and then flushed with 50 cc of
water.
°. Review of the physician order dated 2/28/02 reads,
"Feed 1 can of Choice TF (Tube Feeding) Q 6 (every 6) hours Bolus
- 6 oz water flush after Choice TF." (6 oz = 180 cc.) The nurse
gave a total of 100 cc less water than ordered at this time.
p. Review of the Intake and Output monitoring record since
re-admission to the facility on 2/28/02, lacks any documentation
from 2/28/02 through 3/3/02. There are Intake and Output
18
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monitoring records for 3/4/02 through 3/6/02, but none are
complete.
26. Further review of the label from the tube feeding revealed
that Choice DM is a nutritional supplement for oral use for
persons with diabetes. This is different from Choice DM Tube
Feeding (which the physician ordered) that is nutritionally
complete tube feeding formula for persons with diabetes. In
addition the surveyor noted that the order for 4 cans of Choice
DM (Non-Tube feeding formula) provided only 892.8 calories per
day.
27. The nutritional breakdown for Choice DM vs. Choice TF for 4
cans per day are as follows:
Choice DM - oral Choice TF
892.8 calorie (4 cans) 1017.6 calories (4 cans)
37.4 grams of protein 43.2 grams of protein
816 mg sodium 816 mg of sodium
Four cans formula per day only provided 73% of the Recommend
Dietary Intake for vitamins and minerals, and the resident was
not on a multivitamin supplement.
28. At 65 inches and 111.8 (weight taken on 2/28/02), the
resident's ideal body weight should be 142 pounds with a range of
127 to 156 pounds. At 111.8 pounds the resident is 78% of ideal
body weight.
29. The resident's BMI is only 18 which is indicative of being
severely underweight. Normal is 19 to 27.
19
f (
30. Albumin of 2.4 is indicative of moderate protein depletion.
31. The method of calculating protein needs of a resident with
pressure sores would be 1.2 to 1.5 grams per kg per day or up to
1.9 grams per kg per day with compromised pulmonary status.
32. Protein needs of Resident #27 are estimated at 61 to 76.2
grams per day with a pressure sore and 61 to 96.5 grams per day
if also pulmonary compromised. Four cans of tube feeding
administered to Resident #27 would provide only 40 to 60% of
protein needs regardless of which formula was used.
33. On 3/6/02, an interview was held with the facility's RD.
She stated that she had been ill recently and had not planned on
coming in until the survey team requested her presence. The RD
does not have a replacement.
34. The RD was shown the note written on Resident #27 on 3/4/02,
by the facility Dietary Manager. The note reads, "Resident
returned from the hosp. (Hospital) to be bolus feeding, RD
notified, no problems with feedings or weight at this time."
35. The RD stated that calculating the nutritional needs was not
the Dietary Manager's duty. The RD stated that she spoke with
the nurse who admitted the resident to the facility on 2/28/02
and told the nurse that the formula was not suitable for this
resident and the resident had been on NutriVent previously
because of a history of Chronic Obstructive Pulmonary Disease.
However, the RD was not sure whether the amount of calories was
brought up as an issue at this time.
20
36. On 3/6/02, the nursing staff notified the physician that the
resident was only receiving 892 calories per day. Per the RD the
physician did not want to change the tube feeding back to
NutriVent but now increased the Choice DM TF to six cans per day.
37. An RD statement added to the note from 3/6/02 stated that
the change in tube-feed formula had been made. On 3/7/2 at 9:00
A.M., the survey team discovered the tube feeding was being given
was still not correct. The tube feeding used was still the oral
supplement and not the formula specifically designed for tube
feedings.
38. Review of the latest MDS (Minimum Data Set) dated 11/22/01,
was generated for an admission. The RAP (Resident Assessment
Protocol Summary) triggers for both Tube Feeding and
Dehydration/Fluid Maintenance. The tube-feeding summary reveals
that the resident has a Gastrostomy tube and has had problems
with aspiration. The dehydration summary reveals that due to
decreased independent access to fluids the resident is at risk
for electrolyte imbalance and the team will proceed to care plan.
The plan of care was unavailable on the chart. The surveyor
requested the facility to bring all the old charts from medical
records. Extensive search of all records by facility staff and
surveyor failed to find any written care plan generated from this
MDS. Review of the interdisciplinary care plan conference sheet
reflects only the original admission conference from 10/30/01.
21
{
Also, no written care plan could be located from the resident's
original admission care plan meeting on 10/30/01.
39. A 2-week Interim Nursing care plan for pneumonia is dated
2/28/02. Interim care plans for dehydration reads, flush with
water every shift (no amount was indicated), feedings per order,
weight, Intake and Output and HOB up. This is not dated.
40. Interview with MDS Coordinator on 3/6/02, revealed that she
was sure a care plan had been written on 11/22/01, but she could
not explain how the Interdisciplinary work sheet was void of
signatures for that meeting. The MDS Coordinator stated the she
felt she had written a care plan, but she could not find it.
41. Extended Survey Date: 3/13/02
a. Review of Resident #27 I & O (Intake and Output) record
since 3/8/02 indicates that on 3/8/02 the I & O record is
incomplete. Neither surveyor nor the charge nurse could locate
any documentation of I&0 from 3/9/02 through 3/12/02.
b. Resident #27 remains on the 6 cans of Choice DM TF/day.
Therefore, the resident's calories are still at 70% of what
he/she needs according to calculations of height, weight and
metabolic needs to heel pressure sores and promote weight gain.
c. The resident's weight on 3/12/02 was 111 pounds.
Previous weight on 2/28/02 was 111.8 pounds.
d. The RD note dated 3/12/02, reveals a request to the
physician that the resident be changed to NutriVent 5 cans per.
However, even with this formula change, the resident would only
22
( (
be at 90% of his/her caloric needs. If the formula were changed
to NutriVent, the protein needs of the resident would be met, but
as of 3/13/02, the resident is receiving only 82% of his/her
protein needs.
42.
43.
Tag 327 Requirement:
Based on observations, clinical record review and interviews
with the resident (agreed to have interview printed), the MDS (Minimum
Data Set)
Dietician
resulting
(Resident
44.
Coordinator, Director of Nursing (DON) and the Registered
(RD), the facility failed to provide adequate hydration
in severe dehydration and a 9-day hospital stay for 1 of 13
#27) active sampled residents.
This is evidenced by:
1. Resident #27, who receives all hydration and nutrition
via Gastrostomy Tube, being admitted to the hospital with
Sepsis from a UTI (Urinary Tract Infection) and severe
dehydration as evidenced by elevated temperature of 101.7 F
and abnormal lab, results including elevated WBC (White
Blood Count), sodium, BUN (Blood Urea Nitrogen) and
Creatinine.
2. Incomplete documentation on the MAR (Medication
Administration Record) of amount of fluids and tube feedings
given prior to admission to the hospital and after
readmission to the facility on 2/28/02.
23
45.
( (
3. Incomplete Intake and Output monitoring records for
fluid administration for residents on Tube Feedings per
facility protocol.
4. Observation of a nurse providing inadequate amounts of
water flush ordered by the physician for Resident #27.
5. Failure to develop or implement a care plan for
rehydration/fluid maintenance as indicated by RAPs on
11/22/01.
6. After hospitalization for rehydration on 2/28/02,
facility staff failed to implement the systems that would
identify and prevent further dehydration of Resident #27.
The facility did not provide sufficient fluids for Resident
#22 resulting in clinical/physical signs of dehydration. The facility
failed to provide adequate fluids for 4 of 13 (Residents #11, #21,
#22, and #23) active residents sampled and one (RS Resident #37)
random sample (RS) by not having water at their bedside within reach,
observed on 3/4/02 between 9:15 A.M. and 10:30 A.M., during the
initial tour.
46.
The findings include:
la. Resident #27 was readmitted to the facility on 2/28/02
following a 9-day hospital stay. The resident has a history of
CVA (Cerebral Vascular Accident), Dysphagia with Gastrostomy tube
placement for nutrition and hydration, Aphasia Hypertension, and
Seizures.
24
( {
b. Clinical record review revealed that a late entry was
written on 2/19/02 at 3:15 P.M., by facility nursing staff. The
entry reads, "...Unresponsive, cold and clammy, temp taken 101.7
ax (Axillary - meaning under the arm pit - clinical significance,
one must add one degree Fahrenheit to equal an oral temperature) .
- ARNP (Advanced Registered Nurse Practitioner) in to see resid
(Resident) and rec'd order to send to E.R. (Emergency Room) for
eval (Evaluation). ... Approx (Approximate) time of exit of
facility with 911 is 1:45 P.M."
c. Emergency room records were requested and received from
the facility. Review of the E.R. records reveal that the
resident was admitted to the hospital with the diagnosis of
Septic Shock, Dehydration, Pneumonia and Urosepsis.
d. The resident's History and Physical written by the
attending physician on 2/19/02 reads, "The patient is a 74 - year
old --- very well known to me, ...total care in the nursing home,
was seen by my nurse practitioner this afternoon and found to be
febrile with noisy breathing and respiratory distress. 'His/her'
urine color had become extremely dark and she transferred
‘him/her' to the emergency room where 'he/she' was evaluated and
found to have evidence of elevated WBC count, infiltrate in the
right lower lobe, and severely hypotensive. 'He/she' was fluid
resuscitated and diagnosed as septic shock, stabilized in the
Emergency Room and transferred to the floor for continued care."
The note continues, "GENERAL: The patient is conscious, barely
25
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responsive, barely opening 'his/her' eyes to command, but does
not seem to be in acute distress. VITAL SIGNS: 99.5, 64
regular, 24, 102/50 now. Height 5'10, weight 1131b 4 oz.
..-ASSESSMENT: 1. Pneumonia. 2. Urinary Tract Infection with
sepsis. 3. Cerebrovascular Accident with hemiparesis and
contractures on the right."
e. The first available laboratory work-up is dated on
2/20/02 and was on the resident's facility clinical record.
- WBC = 40.7 H (High) - Reference range = 4.8 - 10.8 thou/uL
- BUN 74 H - Reference range = 8 - 23.0 mg/dL
- Creatinine 1.6 H - Reference range = 0.8 - 1.5 mg/dL
- Sodium = 168 H - Reference range = 137 - 145 mmol/1
~ Potassium = 3.0 L (Low) - Reference range = 3.5 - 5.1 mmol/1
108 mmol/1
'
- Chloride = 128 H - Reference range = 95
- Total Protein = 5.7 L - Reference Range = 6.3 - 8.2 g/dl
- Albumin = 2.4 L - Reference range = 3.2 - 5.0 g/dl
f. The preceding labs were drawn at the hospital on
2/19/02. Resident #27's calculated serum osmolality was 375,
Sodium was 168, BUN was 74 and BUN/Creatinine ratio was 46.
These laboratory results are indicative of severe dehydration.
g. Dehydration is indicated when: Serum Osmolality is
greater than 295, Sodium is greater than 147, BUN is greater than
10 and the BUN/Creatinine ratio is greater than 25.
h. Review of the nurses' notes prior to 2/19/02, does not
indicate that the resident had refused any tube feeding or water
26
flushes. The only documented incidences of the resident pulling
apart the connection of the Gastrostomy tube from the pump was
noted on 1/23/02 and 1/31/02.
i. Prior to the resident's admission to the hospital on
2/19/02, the resident was receiving NutriVent 42cc/hr via pump
with 200 cc of flush per shift and 50 cc of water before and
after medications. The resident was receiving medications at
6:00 A.M., 2:00 P.M., 9:00 P.M. and 10:00 P.M. This would equal
1000 cc per day of free water plus 787 cc of free fluid from the
tube feeding in a 24-hour period. This order was written on
2/5/02.
j- Review of the resident's February MAR reveals
documentation omissions for varying shifts for 200 cc water
flushes for eight of nine days (2/11/02, 2/12/02, 2/13/02,
2/15/02, 2/16/02, 2/17/02, 2/18/02 and 2/19/02) before the
hospitalization. The water flushes that were to be given before
and after medications show omissions on varying shifts on 2/5/02,
2/9/02, 2/11/02, 2/12/02, 2/13/02, 2/15/02, 2/16/02, 2/17/02,
2/18/02 and 2/19/02.
k. The facility's Policy and Procedure entitled - SPECIAL
NEEDS: ENTERAL FEEDINGS - reads, "9. Enteral feeding intake is
recorded on the Enteral Feeding guide and incorporated into the
clinical record on the shift/24 hour Intake totals of the Intake
and Output monitoring sheet in the record."
27
( (
1. The surveyor requested all copies of the Intake and
Output monitoring sheets for Resident #27. Even though the
resident had been on Gastrostomy tube feedings since 10/4/01, the
only records that could be found start on 1/15/02.
m. Review of the Intake and Output monitoring sheets
reveal the documentation to be incomplete. Indeed, since the new
order for tube feeding and fluids was written on 2/5/02, no
shifts are complete in documentation of Intake and Output
monitoring. In fact, all documentation of Intake and Output
monitoring cease on 2/10/02.
n. Review of the physician's discharge summary from the
hospital for Resident #27, dated 2/28/02, reads: "Course and
Progress: ...Since patient was getting continuous infusion, and
apparently there has not been proper monitoring, I decided to
place the patient on bolus feeds with water supplements."
oO. On 3/5/02 at approximately 8:00 A.M., the surveyor
observed the facility staff nurse administer the tube feeding.
The nurse aspirated for residual but did not check the
Gastrostomy tube for placement. The nurse then administered 30
cc of water, one can of Choice DM and then flushed with 50 ce of
water. Review of the physician order dated 2/28/02 reads, "Feed
1 can of Choice TF (Tube Feeding) Q 6 (every six) hours Bolus -
60z water flush after choice TF."
6 oz = 180 cc
28
( (
The nurse gave a total of 100 cc less water than ordered at this
time.
p. Review of the Intake and Output monitoring record since
re-admission to the facility on 2/28/02 lacks any documentation
from 2/28/02 through 3/3/02. There are Intake and Output
monitoring records for 3/4/02 through 3/6/02, but none are
complete.
q. Laboratory reports that show improved status after
hospitalization dated 3/7/02 are as follows:
- BUN = 10 - normal range = 8 - 23.0 mg/dL
- Creatinine = 0.6 L - normal range = 0.8 - 1.5 mg/dL
- BUN/Creatinine Ratio = 12 - normal range = 12-20
- Sodium = 136 L - normal range = 137-145
- WBC = 13.4 H - normal range = 4.8 - 10.8 thou/uL
r. Review of the latest MDS (Minimum Data Set) dated
for both Tube Feeding and Dehydration/Fluid Maintenance.
s. The tube-feeding summary reveals that the resident has
a Gastrostomy tube and has had problems with a aspiration. The
dehydration summary reveals due to decreased independent access
to fluids the resident is at risk for electrolyte imbalance and
the team will proceed to care plan.
t. The care plan was unavailable on the chart. The
surveyor requested the facility to bring all the old charts from
medical records. Extensive search of all records by facility
staff and surveyor failed to find any written care plan generated
29
(
from this MDS. Review of the interdisciplinary care plan
conference sheet reflects only the original admission conference
from 10/30/02. Also, no written care plan could be located from
the resident's original admission care plan meeting on 10/30/01.
u. Interview with MDS Coordinator on 3/6/02, revealed she
was sure a care plan had been written on 11/22/01, but she could
not explain how the Interdisciplinary work sheet was void of
signatures for that meeting. The MDS Coordinator stated she felt
she had written a care plan but she could not find it.
Vv. A 2-week Interim Nursing care plan for pneumonia is
dated 2/28/02. An interim care plan for dehydration reads: flush
with water every shift (no amount was indicated), feedings per
order, weight, Intake and Output and HOB (head of bed) up. This
is not dated.
w. Due to lack of developing and implementing a plan of
care, observation of facility nurse giving inadequate fluid, and
incomplete and inaccurate documentation fluid intake and output,
there is no indication that dehydration will not re-occur for
this resident.
x. During the Extended Survey on 3/13/02 the Intake and
Output monitoring record was reviewed. The record indicates
incomplete or no documentation for 3/08/02 through 3/12/02.
2a. Resident #22 was admitted with multiple diagnoses
including but not limited to Diabetes Mellitus, Cerebral Vascular
Accident, Seizures, Simple Schizophrenia and Depression.
30
( i
b. During initial tour on 3/4/02 at approximately 9:45
P.M., the resident was observed lying flat in bed. The
resident's lips were observed to be cracked and dry. The water
pitcher was observed to be out of reach from the resident. A call
light was observed to be in reach of the resident. The resident
stated, "I can't use the call light because I can't use my
hands." The resident's care plan revealed, "Special call light-
keep so she can press it with her chin." During the initial tour
the call light was observed to be approximately 12 inches from
her chin.
c. The resident's medical record MDS revealed, "2/2
(limitation both sides / full loss) of arms hands legs and feet."
The MDS also revealed, "4/2 (Total Dependence / one person
assist) for eating."
d. The resident's Certified Nurse Aide (CNA) Care Plan on
3/4/02 revealed no documentation of fluids offered from March ist
through March 4th.
e. The resident was observed in her room on 3/4/02 at
approximately 11:35 A.M., being assisted with lunch. Resident's
meal tray contained 90 cc of apple juice and 240 cc of low fat
milk. The resident requested water and refused the other liquids
on her meal tray. The resident was heard requesting crackers for
her tomato soup. The CNA assisting the resident stated there
were no crackers. The resident stated, "Then I don't want the
soup, unless I have crackers." A large container of crackers
31
{
were observed in the unit food pantry. Following surveyor
intervention, the CNA provided crackers for the resident. During
the meal, the resident was observed to drink only water.
f. At 1:00 P.M. on 3/4/02, the resident was observed up in
a Geriatric Chair with both feet elevated, and the call light was
not placed under her chin. The call light was attached to a top
sheet covering the resident and was approximately 18 inches from
the resident's chin.
g. Staff was observed at 1:30 P.M. and again at
approximately 2:35 P.M., entering the resident's room no water
offered to the resident. At 2:45 P.M., the resident was placed
back in bed. No fluids were offered to the resident after
placing the resident in bed.
h. At 2:55 P.M., the hydration cart was observed outside
the resident's room. The dietary aide providing fluids and
supplements did not go into the resident's room. She continued
down the hallway offering other residents nourishments. The
Nourishment List revealed that the resident received nourishment
once on the March 1, 2, and 3 but did not receive nourishment on
the 4th. The Nourishment Cart is passed twice a day, afternoon
and evening.
i. During an interview with the resident, on 3/4/02 at
approximately 3:00 P.M. stated, "No I was not given any water.
The only time I get any water is at meals, when I ask for it.
Will you give me some water I'm thirsty." The resident's lips
32
( (
were observed dry and cracked. The resident drank approximately
270 cc of water. Observation of the resident's call light was
not placed under her chin as care planned.
3. On March 5, 2002, the CNA Care Plan was backdated
reflecting that the resident had received fluids from the 1st
through the 4th during the evening shift. It also revealed that
the resident had received fluids on the 5th during the early
morning shift.
k. On 3/5/02, the resident was observed at 8:15 A.M. in
bed. The resident's lips were dry. She stated, "I'm thirsty".
At 8:30 A.M., the resident was observed being assisted with
breakfast, drinking. The resident's call light was placed
approximately 12 inches from her chin (out of reach) .
1. The resident's bedside water pitcher when observed from
a 90 cc cup with a straw was half filled with water. The
resident's bedside water pitcher when observed from 1:45 P.M.
until 4:30 P.M., was one fourth filled and a 90 cc cup was half
full. The resident's call light was observed not placed under
her chin.
m. Observation of the resident from 3/5/02 at 5:00 P.M.,
found the resident's lips were dry and cracked with dry mucosa of
her mouth and red, cracked tongue. Resident stated, "The last
time I received water was during lunch and when I received my
medications. I only like water with my meals."
33
( (
n. On 3/6/02 at approximately 9:30 A.M. and again at 11:30
A.M., the resident water pitcher was observed three quarters full
and the plastic cup was half full. Resident stated, "No one gave
me water, I'm thirsty." The resident's call light was not placed
under her chin.
°. On 3/6/02 at approximately 4:00 P.M., the resident was
observed with cracked dry lips, dry mucosa of the mouth and a
dry, cracked, red tongue. The resident requested a drink of
water and consumed approximately 240 cc of water.
p- A review of the CNA Resident flow sheet for January and
February 2002 revealed that the resident was offered fluids, but
no refusals were documented.
q- The resident's medical record reveals that the resident
refuses to have blood drawn, periodically refuses to take her
Dilantin, and on occasions refuses to eat (three times in January
and February) .
r. The resident's Nutritional Risk Assessment on 12/18/01
revealed that the resident is at high risk nutritionally.
s. The facilities procedures for hydration risk for
provided "sufficient fluid" to meet their identified needs. 2)
Residents will be monitored by nursing staff for any clinical
signs and symptoms of possible insufficient fluid intake. 3)
Alternatives will be offered to encourage residents to take
sufficient fluids as needed. 4) If a resident is at risk for
dehydration, fluids will be offered at least every 2 hours.
34
(
t. Nursing staff should offer fluids whenever providing
care to the resident, no matter how small.
u. During an interview with the Dietitian on 3/6/02 at
approximately 1:30 P.M., the Dietitian revealed she was unaware
the resident was not accepting dietary fluids. The Dietitian
recalculated her fluid needs which remained as documented as on
12/18/01.
v. An interview with the DON and the Care Plan Coordinator
verified they were unaware of the resident's lack of fluid
intake, and subsequently, the resident was not identified as high
risk for dehydration; therefore, the facility's procedures were
not implemented for dehydration
3a. Resident #21 was readmitted to the facility on 1/16/02
with diagnoses including left above knee amputation, Type 2
Diabetes, Cerebrovascular Accident (stroke), Depression and
Anemia.
b. Review of the Minimum Data Set (MDS) significant change
assessment completed on 01/30/02 revealed that the resident had
problems with diarrhea and constipation, swallowing problems and
had an indwelling catheter. The resident needed limited
assistance for eating and had poor vision. The MDS noted that the
resident had experienced pneumonia and a Urinary Tract Infection
in the last 30 days. The resident also had a fever in the last 7
days.
35
c. Review of the Resident Assessment Protocols (RAPs)
revealed that the resident triggered for dehydration secondary to
history of Urinary Tract Infections, Pneumonia and recent major
surgery. He also has a supra pubic catheter and often suffers
from constipation. The RAP concluded that the resident continued
to be at risk for electrolyte imbalance and the facility would
proceed to care plan. The Nutritional Status RAP indicated that
the resident had some swallowing problems, was seen by the speech
therapist, and was changed to a Mechanical Soft diet with Nectar
Thick Liquids. The RAP concluded that the facility would proceed
to care plan to monitor weight status.
d. Review of the Physical Assessment completed by the
Advanced Registered Nurse Practitioner (ARNP) on 01/29/02
revealed that she had documented that the staff were concerned
about the resident having diarrhea for 1 week. She documented "TI
was not made aware of diarrhea last wk (week).Water was not
readily accessible when I was in room." Physical assessment
included: "obvious wt. (weight) loss - noted especially in face."
"voice hoarse and scratchy" "mucus membranes somewhat dry." The
assessment indicated that the diarrhea may be secondary to
antibiotics. The documented plan stated, "Staff reminded to keep
water with straw at bedside." The ARNP ordered lab work.
e. Review of the lab data dated 01/30/02, indicated normal
lab values except for a slightly elevated Blood Urea
36
Nitrogen/Creatinine (BUN /Cr) ratio of 22 (reference range 12-
20).
f. Review of the Physician's Telephone Orders dated
01/30/02, revealed a nursing request for sugar-free pudding
between meals, three times a day and on 02/09/02, the physician
ordered a diet change to nectar thick liquids secondary to
swallowing problems at the recommendation of the Speech
Therapist. A Modified Barium Swallow was conducted on 02/12/02.
g. Review of the resident's Interdisciplinary Care Plan
dated 01/25/02, revealed that there was no care plan to address
the resident's risk for dehydration. Review of the speech care
plan, dated 01/25/02, revealed that the therapist noted that the
resident had decreased oral motor strength, range of motion and
coordination. The approaches included: consistency modification
and compensatory techniques. The care plan did not address the
use of thickened liquids and risk for dehydration and aspiration.
Review of the nutrition care plan, dated 01/16/02, identified the
resident at risk for weight loss. Approaches included "MBS to be
done to assess swallowing", "1/25/02 SLP (speech language
pathologist) as ordered with D/C (discontinue) 2/22/02",
"aspiration precautions", and "2/9/02 Mech (mechanical) soft w/
(with) ground meat and nectar thick liquids NAS (No Added Salt)
RCS (Reduced Concentrated Sweets). The care plan did not address
the resident's risk for dehydration and approaches to monitor for
dehydration.
37
h. Review of the Nutritional Risk Assessment completed on
01/18/02, revealed that the resident's fluid needs were
determined to be 2430 cc per day. The Registered Dietitian (RD)
assessed the resident to be consuming 26-75% of planned meals and
1500 to 2000 ce of fluid per day. She noted that the resident
was at high nutritional risk secondary to multiple drugs,
diagnoses, fair appetite, adjust problems following amputation
and potential for skin breakdown. She did not address the
resident's risk for dehydration with inadequate fluid
consumption.
i. Review of the Nutritional Progress Notes dated
01/30/02, completed by the Certified Dietary Manger, revealed
that the resident had a poor appetite and was depressed. She
documented that she would notify the RD.
j. The RD documented on 01/30/02, that the resident
weighed 168 pounds (a 10 pound weight loss since readmission) .
She further documented, "It is my opinion that this is actually
the lst wt. (weight) after his amputation + (and) hosp.
(hospital) stay." Her plan was to monitor weekly weights and
contact the RD with concerns.
k. Review of the resident's weekly weights revealed that
the resident weighed 178 pounds on admission on 01/16/02,
decreased to 172 pounds on 01/23/02 and decreased to 168 pounds
on 01/28/02. Weight remained stable at 168 pounds on 02/04/02,
gradually increased to 171 pounds on 02/11/02 and 174 pounds on
38
02/18/02. The next recorded weight revealed a decrease to 168
pounds on 02/24/02 and an increased back to 174 pounds on
03/02/02.
1. There was no further documentation by the RD regarding
the resident's fluctuating weights, nutrition or hydration status
in the clinical record.
™m. Observation of the resident on 03/04/02 at noon,
revealed the resident in bed eating lunch with head of bed ata
30-degree angle. The resident was served ground meat and nectar
thick liquids, which included 8 ounces of thickened milk, 4
ounces of thickened water, and 4 ounces of thickened juice. The
resident was observed coughing on the food. He drank only 8
ounces of thickened milk. Staff were not observed offering
assistance with the meal or offering the resident other liquids
from his tray prior to removing the tray from the room.
n. Observation of the resident on 03/04/02 at 2:40 P.M.,
revealed the resident in bed in the same position at noon. The
resident had no liquids at the bedside.
°. Observation of the resident on 03/04/02 at 3:00 P.M.,
revealed that the resident was offered only sugar-free pudding
and no liquids from the hydration cart.
p. Observation of the resident on 03/05/02 at 9:05 A.M.,
revealed that there was a cup of thin water with a straw at the
resident's bedside. An empty pill cup was on the bedside table
next to the water.
39
\ f
q.- Observation of the resident on 03/05/02 at 11:10 A.M.,
revealed the resident up in his electric wheel chair in the hall
outside of his room, which was across from the nurse's station.
The resident had a hoarse, dry voice and was complaining of being
thirsty. Resident stated that his mouth was dry. He stated,
"they tell me to ask for something to drink, but how can I when
the don't come in." The resident confirmed he gets pudding
between meals, but no liquids. He stated that he had liquids at
breakfast and 2 puddings as his morning snack. He confirmed that
he had not been offered any other fluids since breakfast. The
resident confirmed that he sometimes gets thin water with his
pills from the nurses. He further stated that there is water at
his bedside, but he can't reach it by himself. He stated, "I'm
blind."
r. Observation of the resident's room at 11:15 A.M.,
revealed no water at the bedside.
s. At 11:17 A.M., the Surveyor asked an aide who was
coming out of the room next door to assist the resident. The
resident asked the aide for water and stated to the aide, "J
should have gotten some (water) this morning, I haven't yet."
t. Interview with the Certified Nursing Assistant (CNA) on
03/05/02 at 11:35 A.M., revealed that the resident had a cooler
in his room with thickened water and he gets things from the
hydration cart. The CNA stated that the resident was up when she
arrived at work at 7 A.M. and had not checked on him. She stated
40
that she had been busy this morning, so she didn't know if he had
been offered any fluids. She confirmed that she did not offer
him anything to drink. She stated that the aides write the
offering of fluids on the ADL (activity of daily living) flow
sheets.
u. The aide entered the resident's room and showed the
surveyor a cooler with cold water that held 2 containers of
thickened water. The cooler was across the room on the resident's
dresser and not accessible to the resident. The cooler had a
screw top lid and could not be opened by the resident. The aide
confirmed that the resident was unable to get fluids on his own.
When told that the other aides had not offered him fluids that
morning, the aide replied, "Well, he gets something from the
hydration cart." The aide confirmed that she was unaware that
the resident only received pudding at 10 A.M. and that no
hydration cart is passed. She was unaware that he receives
pudding and no fluids from the hydration cart when the hydration
aide passes the cart at 2 P.M. and 8 P.M.
Vv. Observation of the resident on 03/05/02 at 11:50 A.M.,
revealed the resident in his room in his electric wheel chair
eating his lunch. The resident confirmed that no one came in and
offered him water that morning. The resident stated, "They meant
to. This happens every day. I only got 2 puddings this morning."
The resident was served 4 ounces of thickened water, 4 ounces of
thickened juice and 8 ounces of thickened milk on his lunch tray.
41
The resident stated that he would drink the beverages with his
meal.
w. Review of the Nursing Aide Care Plan (nurse's aide flow
sheet) for 03/02, revealed that the Dietary section coded the
resident as needing assistance with eating. The Nutrition
section listed the resident's diet, which included the thickened
liquids. It was checked that the resident was at risk for
malnutrition and dehydration and the form stated to record fluids
on the reverse side of the form. The following approaches were
checked: offer/assist fluids each contact; measure fluid intake;
measure fluid output and weigh monthly. The back of the care
plan where the aides recorded meal and fluid percentage intake
and number of times fluids offered was blank for all days and all
shifts for the month when reviewed on 03/04/02.
x. Review of the form on 03/05/02, revealed the form had
been completed during the previous night for all days for the 3
P.M. - 11 P.M. shift and the 11 P.M. - 7 A.M. shift with the 7
A.M. - 3 P.M. shift remaining blank for 03/01/02 through
03/04/02.
y. Observation of the resident's room on 03/05/02 at 4:00
P.M., revealed that the cooler was on the over bed table next to
the resident's bed with a stack of plastic cups to the side. The
cooler was closed and could not be opened by the resident.
Z. Observation of the resident at dinner in the East Wing
Dayroom on 03/05/02 at 5:40 P.M., revealed he drank 4 ounces of
42
i
thickened water and 4 ounces of thickened milk with his meal and
left the dining room. Interview with a staff member revealed
that he had taken away the resident's iced tea because it was not
sent thickened. The staff person was not observed obtaining a
thickened tea from the kitchen for the resident.
aa. Review of Nurse's Notes on 03/06/02, revealed that the
Director of Nursing had recorded in the resident's record on
03/05/02 at 5:45 P.M., that he had sent a staff person to the
kitchen to obtain a cup of tomato soup for the resident because
he could not eat the sliced tomatoes. It was documented@*that the
soup was thickened and given to the resident. There was no
documentation of the amount of soup that the resident ate.
bb. Observation of the snack tray sent to the East Wing on
03/06/02 at 10:05 A.M., revealed that it contained a cup of
pudding for the resident with no beverage.
cc. Review of the Nursing Aide Care Plan sheets on
03/06/02, revealed that the day shift had not recorded the
resident's fluid and food intake and additional offerings of
fluid since 02/28/02.
dd. Observation of the resident's room on 03/06/02 at 11:00
A.M., revealed the cooler that contained the resident's thickened
water was on the bedside table for the other bed in the room,
behind the curtain, out of view and reach of the resident and
staff. The resident was observed in the hall in his wheel chair,
he was lethargic and responding slowly to the staff. The staff
43
nurse sent the resident to the hospital emergency room with
complaint of chest pain.
ee. Review of the 03/06/02 lab data upon return from the
emergency room revealed that the resident's BUN/Cr ratio remained
elevated at 25.4 and the resident had a low Hematocrit level.
These labs may be indicative of a mild dehydration status.
f£. Review of the facility's policy and procedure on
Hydration/Risk for Dehydration revised 08/10/99 revealed the
following:
3. "If identified "at risk", initiate care plan
addressing triggered areas with appropriate interventions.
Communicate approaches to C.N.A.'s and other staff as
needed.”...
4. "The dietician will initiate a timely full
assessment after admission, re-admission and with
significant change to identify potential for risk, correlate
resident information with MDS/RAP trigger for hydration and
guide development of the interdisciplinary care plan as
needed."
5... "Care planning with appropriate interventions will
be implemented."
7. "The resident's hydration status will be monitored
through identified approaches in the care plan.”...
13. "If a resident is at risk for dehydration, fluids
will be offered at least every 2 hours..."
44
4a. Resident #23 RAP summary triggered for being at risk
for Nutrition. The resident was not care planned for Nutrition
Status. Refer to F279. The facility maintained a CNA Nutrition
and Fluid intake sheet for the resident. The resident is at risk
for Nutrition due to senile delusions. The resident's care plan
further states the resident has senile dementia.
b. In January 2002, there was no documentation of fluid
intake on 12 of 186 opportunities to document fluid intake.
Additionally, the resident was documented on 51 other occasions
as either refusing to take fluids or "0" was entered on the CNA
records.
Cc. In February 2002, there was no documentation of fluid
intake on 51 of 168 opportunities to document fluid intake.
Additionally the resident was documented on 19 other occasions as
either refusing to take fluids or "0" was entered on the CNA
records.
d. In March 2002, there was no documentation of fluid
intake on 17 of 45 opportunities to document fluid intake.
Additionally the resident was documented on 1 other occasion as
either refusing to take fluids or "0" was entered on the CNA
records.
5a. Resident #11's RAP summary triggered for being at risk
for nutrition and dehydration. The resident was care planned on
8/23/01 to "encourage PO (by mouth) intake of fluids." The care
plan was updated and the monitoring of the resident's fluid
4S
intake was to be continued. A review of the Certified Nursing
Assistant (CNA) Nutrition and Fluid intake sheet for November
2001 revealed a lack of documentation of fluid intake on 34 of
153 opportunities to document fluid intake. Additionally, the
resident was documented on 13 other occasions as either refusing
to take fluids or "0" was entered on the CNA records.
b. In December 2001, there was no documentation of fluid
intake on 32 of 186 opportunities to document fluid intake.
Additionally the resident was documented on 6 other occasions as
either refusing to take fluids or "0" was entered on the CNA
records.
c. In January 2002, there was no documentation of fluid
intake on 33 of 186 opportunities to document fluid intake.
Additionally, the resident was documented on 2 other occasions as
either refusing to take fluids or "0" was entered on the CNA
records.
48. Tag 490 Requirement:
49. Based on observation of residents and staff throughout the
facility, clinical record review, interview with residents on an
individual basis and in the Resident Group Council, interviews with
the Administrator, DON (Director of Nursing), facility's Consultant RD
(Registered Dietician), MDS (Minimum Data Set) Coordinator, QA
(Quality Assurance) Consultant and facility's staff nurses, the
Administrator failed to monitor staff and intervene in a timely matter
resulting in harm to 3 active residents (Residents #19, #22 and #27)
46
and the struggle for all residents to attain and maintain their
highest level of well-being.
50.
This is evidenced by:
1. Failure to assure that the facility had sufficient
nursing staff to care for all residents.
2. Pailure to follow the facility's Quality Assurance plan
for correction of F241, F281, F353, F364, F426 and F490
resulting in a recitation of these tags at both the annual
standard, and follow- up survey to the complaint dated
1/17/02.
3. Failure to follow policies and procedures resulting in
harm to residents as exhibited by resident's who had
clinical and physical signs of dehydration, weight loss and
pressure sores.
4. Failure to follow facility's policies and procedures to
prevent dehydration and weight loss and pressure sores.
5. Failure to assure that nursing and dietary staff
accurately assess residents, and in a timely manner,
initiated changes when there has been a decline in resident
condition in relationship to hydration and nutrition.
6. Failure to assure that staff developed and up-dated Care
Plans with specific and progressive interventions to prevent
dehydration, weight loss and pressure sores.
47
TTS hs ee ve SENN SOP
7. Failure of MDS staff and facility's interdisciplinary
Care Plan team to assure timely RAIs (Resident Assessment
Indictors).
8. Failure to assure accurate resident clinical records as
evidenced by falsification of records.
9. Failure of the Administrator to effectively and
efficiently oversee and manage the facility led to a
residents severe weight loss and dehydration (Resident #27)
and development of pressure sores (Resident #19).
51. The findings include:
1. The Administration did not require the Director of
Nurses or other facility staff to accurately assess residents and
to develop specific and progressive care plans for these
residents. Refer to F278 G Class II - accuracy of assessments
for Residents #19, #27 and #28. Refer to F279 G Class II -
Accurate and Comprehensive Care Plan for Resident #21, #23 and
#27. This failure by the Administration to require accurate
assessment and, specific and progressive care planning on each
resident contributed to development of pressure sores,
dehydration and weight loss to residents. Refer to F314, F325
and F327.
2. The Administration failed to increase staffing on the
units to assure that adequate staff was available to monitor,
care for, and protect residents from harm. This failure to
increase staffing contributed to the facility's inability to
48
eevee caspases tee
( !
properly assess, develop and up-date Care Plans with specific and
progressive interventions, and to care for, and monitor
residents. Refer to F353, F278, F279, F314, F325 and F327.
3. The Administrator failed to assure that facility's
Policies and Procedures were routinely implemented by nursing and
dietary staff, which resulted in weight loss, dehydration and
pressure sores. Refer to F314, F325 and F327.
4. Administrator failed to assure that the facility's Plan
of Correction for the complaint survey ending on 1/17/02 was
successfully implemented and completed. This is evidenced by the
recitation of the following: F241 E Class III - Dignity of
Residents, F281 D Class III - Professional Standards of Nursing
Care, F353 E Class III - Staffing to meet the needs of all
residents, F364 E Class III - Palatability of food, F426 D Class
III - Accurate administration and distribution of drugs and
biologicals and F490 K Class I - Inadequate Administration.
5. Failure of the Administration to use its recourses
effectively and efficiently to attain the highest practice
physical, mental, and psychological well being of all resident
this facility as evidenced by falsification for records and
citation of Immediate Jeopardy at F325 J Class I and F327 K
Class I.
52. Tag 493 Requirement:
53. Based on observation, review of clinical records, review of
the facility Policy's and Procedures, including Nursing, and
49
i TE
f (
Administration, the Governing Body of the facility failed to assure
that the Policy and Procedures to prevent weight loss, dehydration and
pressures sores were implemented and that the Plan of Correction
established by the facility for a complaint survey ending on 1/17/02
was implemented and successfully completed.
54. This is evidenced by:
1. Failure of the Administrator and the facility's
supervisory personnel to follow the facility's Quality
Assurance plan for correction of F241, F281, F353, F364,
F426 and F490 resulting in a recitation of these tags at
both the annual standard, and revisit survey to the 1/17/02
complaint.
2. Failure of the Administrator and the facility's
supervisory staff to assure that facility Policy and
Procedures were implemented to prevent harm to residents as
outlined by absent, inaccurate or incomplete assessments of
residents, resulting in G Class II Deficiencies at F278 and
F279.
3. Failure of the Administrator and facility supervisory
staff to assure that Policy and Procedures were implemented
to prevent harm to a resident, development of an avoidable
pressure sore, resulting in F314 ataG Class II level.
4. Failure of the Administrator and facility supervisory
staff to assure accurate documentation by staff which
50
resulted in falsification of records and a citation of F492
at a G Class II level.
5. Failure of the Administrator and supervisory staff to
prevent Immediate Jeopardy as outlined in F325 at a J Class
I level (Weight Loss), F327 K Class I level (Hydration) and
F490 K Class I level (Administration) .
5S. The findings include:
1. The Governing Body of this facility did not ensure the
Administration effectively directed staff resulting in harm to
residents. This is exhibited by failure of the supervisory staff
to ensure accurate assessments of residents and the lack of
development of specific, progressive care plans to monitor
residents. Refer to F278 G Class II - plan for Resident #19,
#23, #27 and #28. Refer to F279 G Class II - Accurate and
comprehensive care planning for Resident #21, #23, and #27. This
failure contributed to the development of pressure sores,
dehydration and weight loss to residents. Refer to F314, F325,
and F327.
2. The Governing Body of the facility did not ensure the
Administration and supervisory nursing staff increased staff on
nursing units to ensure adequate nursing staff was available to
monitor, care for, and protect residents from harm. This failure
to increase staffing contributed to the facility's inability to
properly assess and implement updated care plans with specific,
31
to F353, F278, F279, F314, F325 and F327.
3. The Governing Body of the facility did not ensure the
Administration, Nursing, and Dietary Supervisory staff were
utilizing the facility's written Policies and Procedures which
resulted in weight loss, dehydration and pressure sores. Refer
to F314, F325, and F327.
4. The Governing Body of this facility failea to ensure the
facility's Plan of Correction for the 1/17/02 complaint wag
successfully implemented and completed by the Administration and
nursing Supervisory staff. This is evidenced by the reciting of
the following: F241 E Class III - Dignity of Residents, F281 D
Class III - Professional Standards of Care, F353 EB Class III -
Staffing to meet the need of residents, F364 E Class III -
Palatability of Food, F426 D Class III - accurate administration
and distribution of drugs and biologicals, and F490 K Class I -
Inadequate Facility Administration.
5. The Governing Body of the facility did not ensure the
Administration, Nursing, and Dietary Staff used its resources
effectively and efficiently to attain the highest practicable
physical, mental, and Psychological well-being of all residents
in this facility as evidenced by falsification of records and
Citation of Immediate Jeopardy at F325 [ Class I and F327 K
Class I.
56. The above actions or inactions constitute a violation of (1)
52
Section 400.121 (3) (d) Fl. Stat. (2002), which states that the Agency
shall revoke or deny a nursing home license if the licensee or
controlling interest operates a facility in this state that is cited
for two class I deficiencies arising from separate surveys or
investigations within a 30-month period.
57. The above referenced violations constitute the grounds for
the one (1) imposed Class I deficiency.
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
Counts I and II;
B. Impose a license revocation for the violations cited in
Counts I and II, against the Respondent under §400.121(1) and (3) (d),
Florida Statutes;
c. Assess costs related to the investigation and prosecution of
this case pursuant to § 400.121 (2) Fl. Stat. (2002) and;
D. All other general and equitable relief allowed by law.
NOTICE
DESOTO HEALTH & REHABILITATION, L.L.C., d/b/a DESOTO HEALTH AND
REHABILITATION 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).
53
rey insinménnive a:
(
All requests for hearing shall be made and delivered to: Agency
for Health Care Administration, 2727 Mahan Drive, Building 3, Mail
Stop #3, Tallahassee, Florida 32308. Attention: Lealand McCharen,
Agency Clerk.
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 s
Eileen O’Hara Gar¢dia, Esquire
AHCA - Senior Atforney
525 Mirror Lake/Drive, North
Sebring Building, Suite 330D
Saint Petersburg, Florida 33701
(727) 552-1439 (Office)
(727) 552-1440 (FAX)
I HEREBY CERTIFY that a copy hereof has been furnished to Philip
Castleberg, Registered Agent for Desoto Health & Rehabilitation,
L.L.C., 1002 North Brevard Avenue, Arcadia, Florida 34266, by U.S.
Mail and Administrator, Desoto Health and Rehabilitation, 1002 North
Brevard Avenue, Arcadia, Florida 34266 by U.S. Certified Mail, Return
Receipt No.7002 2030 0007 8499 7086 o
Eileen O’ Hara Garcia, Esquire
54
Copies furnished to:
Philip Castleberg
Registered Agent for
Desoto Health and Rehabilitation,
1002 North Brevard Avenue
Arcadia, Florida 34266
(U.S. Mail)
Administrator
Desoto Health and Rehabilitation,
1002 North Brevard Avenue
Arcadia, Florida 34266
(U.S. Certified Mail)
Eileen O’Hara Garcia, Esquire
Agency for Health Care Administration
525 Mirror Lake Drive, North
Sebring Building, Suite 330D
Saint Petersburg, Florida 33701
(Interoffice)
5S
a eer . =
XUVYIvw wire .
FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION: 5
JEB BUSH, GOVERNOR RHONDA M. MEDOWS, MD, FAAFP, SECRETARY
September 25, 2003
Certified Article Number
Administrator
Desoto Health & Rehab, L.L.C 7k60 3901 5844 4609 4575
1002 N. Brevard Avenue SENDERS RECORD
Arcadia, FL 34266
NOTICE OF INTENT TO DENY (#2003006976)
It is the decision of this Agency that the Nursing Home License sénewal plication for Desoto Health &
Rehab, L.L.C. is DENIED.
Pursuant to Section 400.121(3)(d), Florida Statutes (F.S.), the agency shall revoke or deny a
nursing home license if the licensee or controlling interest operates a facility in this state that is cited for
two class I deficiencies arising from separate surveys or investigations within a 30 month period.
You were notified by Administrative Complaint on July 16, 2003 that Desoto Health & Rehab, L.L.C.
was in violation of this section of the Florida Statutes. .
EXPLANATION OF RIGHTS
Pursuant to Section 120.569, Florida Statutes, (F.S.) you have the right to request an administrative
hearing. In order to obtain a formal proceeding before the Division of Administrative Hearings under
Section 120.57(1), F.S., your request for an administrative hearing must conform to the requirements in
Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute.
SEE ATTACHED ELECTION AND EXPLANATION OF RIGHTS FORMS
Sincerely,
e/a
CaraLee S. Stames
Program Manager
Long Term Care Unit
cc: Agency Clerk, Mail Stop 3
Wendy Adams, Mail Stop 3
Fort Myers Field Office ‘
K. Munn, Long Term Care Unit
Legal File, Long Term Care Unit
EXHIBIT
Visit AHCA online at
www. fdhe. state. fl.us
2727 Mahan Drive « Mail Stop #33
Tallahassee, FL 32308
STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
AGENCY FOR HEALTH CARE
ADMINISTRATION,
Petitioner,
vs.
DESOTO HEALTH AND
REHABILITATION, L.L.C., d/b/a
DESOTO HEALTH AND
REHABILITATION,
The Respondent.
oe
AGENCY FOR HEALTH CARE
ADMINISTRATION,
Petitioner,
vs.
DESOTO HEALTH AND
REHABILITATION, L.L.C., d/b/a
DESOTO HEALTH AND
REHABILITATION,
The Respondent.
—_
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STIPULATION AND SETTLEMENT AGREEMENT
— OE LEMENT AGREEMENT
Petitioner, Agency for Health Care Administration (“Agency”) through their undersigned
representatives and DeSoto Health and Rehabilitation, L.L.C. d/b/a DeSoto Health and
Rehabilitation (“DeSoto”), pursuant to Section 120.57(4), Florida Statutes (2001) each
individually, a “party” collectively as “parties,” hereby enter into this Stipulation and Settlement
Agreement (“Agreement”) and agree as follows:
EXHIBIT
iZ
WHEREAS, DeSoto is a nursing home licensed pursuant to Chapter 400, Part Il, Florida
Statutes (2002) and Chapter 59A-4, Florida Administrative Code (2002): and
WHEREAS, the Agency has Jurisdiction by virtue of being the regulatory and licensing
authority over nursing homes pursuant to Chapter 400, Part I, Florida Statutes; and
WHEREAS, the Agency served DeSoto with an Administrative Complaint intending to
revoke DeSoto’s license: and
WHEREAS, DeSoto requested a formal administrative hearing as to the revocation
requested above; and
WHEREAS, the Agency served DeSoto with a Notice of intent to deny DeSoto’s
licensure renewal application; and
WHEREAS, DeSoto requested a formal administrative hearing as to the notice of intent
to deny its licensure renewal application; and
WHEREAS, DeSoto has Presented factors in mitigation of revocation and denial of its
license; and
WHEREAS, the Agency has determined that the factors in mitigation are appropriate;
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 interests 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, DeSoto agrees to a withdrawal of its Petitions
for a Formal Administrative Hearing; agrees to waive any and all appeals and proceedings;
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.
4. DeSoto agrees to participate in a six-month survey cycle commencing from March
2003. DeSoto shall pay the Agency $3,000.00 in Survey fees, to be paid at the completion of the
next survey occurring after the execution of this settlement agreement. The Agency shall
withdraw its Administrative Complaint and its intent to deny DeSoto’s licensure renewal
application based on the mitigating factors presented by DeSoto.
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 and shall be
subject to all applicable Provisions for interest, attorney’s fees, expenses and costs for the
prevailing party.
6. DeSoto neither admits nor denies the allegations in the Administrative Complaint and
the allegations in the notice of intent to deny. The Agency agrees that it will not impose any
further penalty or sanction against DeSoto as a result of the Surveys of March 6-7, 2003,
however, no agreement made herein shall preclude the Agency from imposing a penalty against
DeSoto for any deficiency/violation of statute or rule identified in a future survey of DeSoto,
which constitutes a cumulative fine or an uncorrected deficiency from the Surveys of March 6-7,
2003.
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 attorneys’ fees.
9. This Agreement shall become effective on the date upon which it is fully executed by
all the parties.
10. DeSoto, for itself and for its related or resulting organizations, its successors or
transferees, attorneys, heirs and executors or administrators, does hereby discharge the 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, including any claims arising out of this Agreement, by or on behalf of
DeSoto or related facilities.
11. This Agreement is binding upon all parties herein and those identified in the
aforementioned paragraph twelve (12) of this Agreement.
12. The undersigned have read and understand this Agreement and have authority to
bind their respective principals to it.
13. This Agreement contains the entire understandings and agreements of the parties,
14. This Agreement supercedes any prior oral or written agreements between the parties
15. This Agreement may not be amended except in writing. Any attempted assignment
of this Agreement by DeSoto or related facilities, its successor or any resulting organization shall
be void.
The following representatives hereby acknowledge that they are duly authorized to enter into this
Agreement:
ficothe te debe
DEPUTY SECRETARY
AGENCY FOR HEALTH CARE
ADMINISTRATION
2727 Mahan Drive
Tallahassee, FL 32308
Date signed: IP JBP7 o3
VALDA C. CHRISTIAN, ESQUIRE
GENERAL COUNSEL
AGENCY FOR HEALTH CARE
ADMINISTRATION
2727 Mahan Drive
Tallahassee, FL 32308
Date signed:
cee
JONATHAN S. GRO!
GOLDSMITH, GROUT & LEWIS, P.A.
2180 Park Avenue North, #100
Post Office Box 2011
Winter Park, FL 32790-2011
407/740-0144
Attommeys for Respondent
Florida Bar No. 296066
Date signed: LL “FACE “OR
Docket for Case No: 03-004011
Issue Date |
Proceedings |
Jan. 05, 2004 |
Final Order filed.
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Dec. 02, 2003 |
Order Closing File. CASE CLOSED.
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Nov. 26, 2003 |
Motion to Remand (filed by Respondent via facsimile).
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Nov. 12, 2003 |
Order of Consolidation. (consolidated cases are: 03-003323, 03-004011)
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Nov. 10, 2003 |
Response to Initial Order (filed by J. Grout via facsimile).
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Oct. 30, 2003 |
Initial Order.
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Oct. 28, 2003 |
Notice of Intent to Deny Nursing Home License Renewal Application filed.
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Oct. 28, 2003 |
Petition for Formal Administrative Hearing filed.
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Oct. 28, 2003 |
Notice (of Agency referral) filed.
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