STATE OF FLORIDA fr . AGENCY FOR HEALTH CARE ADMINISTRATION, ~< p, wiih e ‘i; rn a re itjei Op AGENCY FOR HEALTH CARE Are fos ADMINISTRATION, Petitioner, AHCA No.: 2003005916 Return Receipt Requested: v. 7000 1670 0011 4849 4798 7000 1670 0011 4849 4781 FORT PIERCE HEALTH CARE ASSOCIATES, 7000 1670 0011 4849 4859 LLC d/b/a FORT PIERCE HEALTH CARE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Fort Pierce Health Care Associates, LLC d/b/a Fort Pierce Health Care (hereinafter “Fort Pierce Health Care”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, and herein alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $2,500.00 pursuant to Section 400.121, Florida Statutes for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. AHCA has jurisdiction pursuant to Chapter 400, Part II, Florida Statutes. 3. Venue lies in St. Lucie County pursuant to Section Rule 28.106207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Florida Statutes and Chapter 59A-4 Florida Administrative Code. 5. Fort Pierce Health Care operates a 171-bed skilled nursing facility located at 611 S. 13 Street, Fort Pierce, Florida 34950. Fort Pierce Health Care is licensed as a skilled nursing facility under license number 10040953. Fort Pierce Health Care was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I FORT PIERCE HEALTH CARE FAILED TO PROVIDE SERVICES TO PREVENT RESIDENT-TO-RESIDENT ABUSE. SECTION 483.13 (c) (1) (ii) CODE OF FEDERAL REGULATION AS INCORPORATED BY RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (STAFF TREATMENT OF RESIDENTS) CLASS ITI 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Because Fort Pierce Health Care participates in Title XVIII or Title XIX, it must follow certification rules and regulations found in 42 Code of Federal Regulation 483. 8. Fort Pierce Health Care was cited with one (1) Class II deficiency. 9. Based on a complaint investigation that took place on August 3, 2003 and based on facility staff interview, medical record and facility documentation, it was determined that the facility did not ensure that a resident involved in an abuse allegation was protected from further potential abuse while the investigation was in progress (resident #1). The findings include the following. 10. An allegation of sexual abuse involving 2 residents was reported. Resident #1 is a severely cognitively impaired individual (as assessed by the facility Minimum Data Set of 6/16/03), and is unable to verbalize needs (no speech, absence of spoken words), as documented in the MDS, and has no ability to be understood nor to understand spoken words. The resident has multiple diagnoses to include: organic brain syndrome, dementia, depression, convulsions, and dysphagia. Resident #2 was admitted to the facility on 7/23/03 and is moderately to severely impaired cognitively. Admission diagnoses include: early stage dementia, Alzheimer’s disease, hypertension, delusions and stomach cancer. 11. Facility documentation reveals the incident occurred 7/25/03 at approximately 5:30 AM. Resident #2 was reported to have been observed committing a sexual act on Resident #1 at Resident #1's bedside. The room contained 4 beds, of which Residents #1 and #2 occupied separate beds. Upon entering the room at approximately 5:30 AM on 7/25/03, a Certified Nursing Assistant observed Resident #2 in the sexual act, and upon the CNA entering the room, Resident #2 pulled up his/her pants and ran into the bathroom. The resident was noted to have refused to come out of the bathroom for quite some time, with the actual timeframe not available nor known specifically by staff. Documentation further reveals that the facility Charge Nurse informed the staff to "leave the residents alone, they are homosexual, and that it's an issue of resident privacy; their privacy rights must be respected." (This statement made by the Charge Nurse was reiterated during the facility staff interviews conducted on 8/03/03.) The door was closed at that time, leaving the residents unattended nor separated. At some point during breakfast, (specific time unknown), Resident #1 was placed in his/her wheelchair, brought to the common area on the unit for breakfast. An interview conducted with the morning unit nurse on 8/03/03 at approximately 9:07 AM revealed that the resident was placed near the nurse's station for much of the day shift on 7/25/03. Resident #2 was not separated from the unit at that time. Further interview with both the Charge Nurse and unit nurse on 8/03/03 revealed that the residents slept in the same room the night following the alleged incident, 7/26/03, and was not moved until the next morning, (Monday morning). It was also determined that the Director of Nursing was in the building during the morning of the alleged incident, Sunday 7/25/03, and facility staff failed to inform her of the incident. The facility Administrator was not notified until Monday of the alleged incident. Interviews were conducted on Sunday, 8/03/03 at approximately 9:10 AM, with the facility Administrator, Director of Nursing, Corporate Nurse Consultant, weekend Charge Nurse and the specified Unit Nurse. 12. There is no indication in either resident's file regarding any previous acts of homosexuality. Interview with the facility staff on 8/03/03 confirmed that Resident #1 did not have the mental capacity to determine choice of sexual activity. Further review of the resident's Minimum Data Set assessment reveals that the resident is not independent in either bed mobility or transfers, and needs assistance with both. The resident was assessed with a 2/2 on bed mobility (limited assistance with assistance of 1) and 3/2 on transfer (extensive assist with one person physical help). 13. Social Services documentation in the medical record of Resident #1 revealed a note of 7/28/03, (11:00 AM) indicating, "social services director contacted resident family member, (mother) to inform her of negative sexual act committed on her son by another resident. She was informed that the other resident will be moved from that area for the safety of her son." This notification is 3 days after the incident occurred. 14. A morning facility Director's meeting was conducted, as usual, on Monday, 7/26/03 at approximately 9:00 AM, per facility staff interview, (of 8/03/03). It was reported that at that time, the incident was discussed. After the staff meeting, (approximately 30 hours after the incident occurred) an investigation was launched, the residents were separated to opposite ends of the building, and the reporting process was started. The local law enforcement was contacted and reported to the facility regarding the allegation. 15. It was determined that the facility failed to ensure that a resident (Resident #1) was kept safe and free from potential further harm during the investigative process. 16. Based on the foregoing, Fort Pierce Health Care violated 483.13 (c)(1){ii), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II violation pursuant to Section 400.23(8) (b), Florida Statutes, which carries in this case, an assessed fine of $2,500.00. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Fort Pierce Health Care on Count I. 2. Assess against Fort Pierce Health Care an administrative fine of $2500.00 on Count I for violation as cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable 4, Grant such other relief as the court deems is just and proper on Count I. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2002). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308, RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (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. . (4) Alba M. JA) Bod. Assistant General Counsel Agency for Health Care Administration 8355 N. W. 53 Street Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 E. tiffany Drive - Suite 100 West Palm Beach, Florida 33407 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Vincent Cacciatore, Administrator, Fort Pierce Health Care, 611 S. 13 Street, Fort Pierce, Florida 34950; Fort Pierce Health Care Associates, LLC, 10210 Highland Manor Drive - Suite 410, Tampa, Florida 33610; CT Corporation System, 1200 South Pine Island Road, Plantation, Florida 33324 on this gh day of Oc tober) , 2003. Alba M. 2) Kad s 5

Docket for Case No: 03-004498