STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTR Ff ILE D AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2003009501 AHCA No.: 2003008457 Vv. Return Receipt Requested: 7002 2410 0001 4237 0089 SEFARDIK ASSOCIATES, LLC, d/b/a 7002 2410 0001 4237 0096 NURSING CENTER AT MERCY, 7002 2410 0001 4237 0102 Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Sefardik Associates, LLC. d/b/a Nursing Center at Mercy (hereinafter “Nursing Center at Mercy”), pursuant to Chapter 400, Part II, and Section 120.60, Fla. Stat., and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $32,500.00 pursuant to Section 400.23(8), Fla. Stat. (2002), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Nursing Center at Mercy pursuant to Section 400.23(7) (b), Fla. Stat. Division of Administrative Hearings Tek 3. This is an action to impose a $6,000.00 survey fee pursuant to Section 400.19(3), Fla. Stat. JURISDICTION AND VENUE 4, This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat., and Chapter 28-106, F.A.C. 5. Venue lies in Miami-Dade County, pursuant to Section 400.121(1) (e), Fla. Stat., and Rule 28-106.207, Florida Administrative Code. PARTIES 6. 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, Fla. Stat., (2002), and Chapter 59A-4 Florida Administrative Code. 7. Nursing Center at Mercy operates a 120-bed skilled nursing facility located at 3671 South Miami Avenue, Miami, Florida 33133. Nursing Center at Mercy is licensed as a skilled nursing facility; license number SNF1627096; certificate number 11022, effective 10/31/2003 through 02/29/2004. Nursing Center at Mercy 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. 8. Nursing Center at Mercy participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A- 4.1288, F.A.C. COUNT I NURSING CENTER AT MERCY FAILED TO THOROUGHLY INVESTIGATE ALL ALLEGATIONS OF ABUSE AND REPORT RESULTS OF ALL INVESTIGATIONS TO THE ADMINISTRATOR OR HIS/HER DESIGNEE AND TO OTHER OFFICIALS IN ACCORDANCE WITH STATE LAW TITLE 42, Section 483.13(3)AND 483.13(4), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code CLASS I DEFICIENCY 9. AHCA re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 10. During an unannounced Licensure and Re-certification survey conducted on 10/27-31/2003 and based on staff, resident, family interview and record review the facility failed to thoroughly investigate all allegations of abuse and report the results of the investigations to the Administrator or his/her designee and to other officials in accordance with state law for eleven (11) of eleven (11) grievances or adverse incident reports reviewed. (R's #6, #13, #17, #29, #32, #33, #34, #35, #36, #41, #42). Findings include: 11. Record review of the grievance for resident #36, filed by the resident's family on 6/30/2003, revealed that on 6/29/2003 at 9:00am, the resident was "pushed down on a shower chair and that a Certified Nursing Assistant (CNA) poured hot oy water on him/her." Family stated that the resident had two bruises with fingerprints under each arm, indicating that someone had held the resident too tightly. Further record review revealed on 7/2/2003, following the incident, an assessment was done by the Abuse Coordinator, revealing a discoloration the size of a dime under the resident's arm. Nothing else was documented as to the CNA involved in the incident. Review of the resident's Minimum Data Set (MDS) revealed the resident to be severely impaired and unable to provide information regarding the incident. Further review of the notes written by the Abuse Coordinator revealed the resident has “fragile skin" leading to the bruising. There is no mention in the grievance where the Abuse Coordinator addresses the issue of the resident being pushed down onto the shower chair and hot water being poured onto the resident by the CNA. In an interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, she revealed that after assessing the resident no further investigation was done and the CNA responsible was not identified in an attempt to identify and remove any threat to residents. 12. Review of the grievance filed by the family for resident #34 on 6/23/2003, revealed a CNA was reported to tell the family member to buy the resident clothes that are easier to use or the CNA is "bound to take off the resident's head one of these days". This CNA also was reported by the family member that they were told to remove the resident's dolls from the closet because they were falling on her (CNA's) head. In a review of the investigation, the CNA was identified and was counseled on 6/24/2003. Review of the employee file for that CNA revealed the CNA has been switched from wing to wing in the facility because of other unsatisfactory related issues regarding her work ethics and attitudes. A review of the CNA's performance evaluation, dated 9/25/2003, revealed "unsatisfactory" ratings in behavioral patterns and interpersonal relationships, however, the CNA continued to have direct contact with residents with no attempts to address her behavior issues. During the survey, it was discovered the CNA was employed by the facility and on vacation at the time of the survey. 13. Review of the grievance filed by resident #17, on 10/14/2003, revealed that the night staff are "rough" with him/her resulting in marks on his/her arms. Notes on the grievance form and interview with the Abuse Coordinator on 10/30/2003 at about 3:00pm, revealed that the resident was assessed by the Social Worker (Abuse Coordinator) and the marks did not appear to be as result by being grabbed. However, there was no further investigation in order to determine the identity of the CNA with the grievance marked as being resolved. wn 14. Review of a grievance filed by a family member for Resident #29 on 8/5/2003, revealed that the family noticed marks on the resident's face. The family member also noted seeing two other resident's with similar marks on their face. The documentation revealed that the assessment done by the Abuse Coordinator revealed that the probable cause was the call bell clip being too close to the resident's face while the resident was sleeping. The grievance was marked as resolved. The investigation failed to interview the CNA's or staff identified on the report. Interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, revealed that there was no further investigation done after it. was assumed that the bruises were caused by the call bell clips. The other two residents, mentioned as having the same bruises, were never identified and there was no investigation done regarding their bruises. 15. Review of the clinical record for resident #13 revealed that according to the nurses' notes dated 10/20/2003 at 9:00 PM the resident was noted to be sitting in his/her bed in the low position with a mattress on the floor. The resident was found to have a "small laceration from unknown origin noted on nose." The note continues that 4x4 gauze was applied and that there was no further bleeding. The nurses' notes dated 10/21/2003 at 11:30 AM again mentions that a small laceration is noted on the nose. The physician was called and an x-ray was ordered. Continued review of the clinical record reveals that an x-ray of the nasal bones was done on 10/21/2003. The report states, " There is a cortical irregularity with destruction of the spine of the nasal bone... ". The stated impression by the radiologist is a nasal bone fracture. (a) On 10/29/2003 at approximately 11:00 AM the Social Worker was asked if any investigation had been done regarding the small nasal laceration resulting in a fracture. According to information left for the surveyors, the investigation consisted of speaking with the employees involved. The documentation is not timed nor signed. Further interview with the Social Worker on 10/30/2003 at 3:00pm, revealed that an assessment of the resident revealed that he/she is restless, which was assumed to be the cause of the nose fracture. There was no further action taken to identify the CNAs or witnesses as to how the resident obtained the fracture. Interview with family member of resident #13 on 10/31/2003 at 1:10pm revealed that she arrived to the facility at 6:45pm and the resident was lying on the floor mattress, had a patch on his/her nose full of blood and had also a cut under his/her right eye. It seemed very deep and the eye was swollen and bruised. Asked the nurse what happened and nurse replied that the nurse from previous shift told her resident was scratching. Relative said that she couldn't believe it. Took nurse to the room and told nurse: "This is not a scratch". Nurse helped relative to put resident back on bed. Resident was not able to tell what happens due to communication problems. The nurse changed resident's patch and said she was going to file an incident report, relative wanted a copy of that report but nurse told her they were not able to give a copy. Administrator or Social worker never spoke with the family about it. Family was not notified. As far as she knows resident was not taken to emergency room but a few days later the doctor notified resident's spouse that the resident had a fracture on his/her nose. Family was not aware of an investigation being conducted. 16. Review of the clinical record for resident #41 reveals that the resident was admitted to the facility on 7/22/2003 with the diagnosis of syncope and ASHD. According to the Nursing Assessment Summary dated 7/22/2003 the resident ambulates alone or with assistance. It also indicates that the resident is alert. Nurses! notes dated 7/29/2003 reveal that the resident is alert and oriented times’ three. Progress notes dated 7/22/2003 at 7:25 PM indicate that the resident is alert and oriented times three to name, place and time. A mattress was placed on the floor at bedtime and the bed is placed in the lowest position. The note further reveals that a falling star is placed on the resident's door. The resident is unable to walk by her/himself and requires total assistance for bed mobility and transfers. According to the Fall Assessment dated 7/22/2003 the resident scored a "9." According to the form a score of 10 or above indicates a risk for falling. (a) Review of the nurses' notes dated 8/01/2003 at 2:40 AM state that the resident was found on the floor at bedside with the Certified Nursing Assistant at the resident's side. The resident is quoted as saying, "I was trying to go to the bathroom and I slipped." A hematoma was noted on the back of the resident's head. On 8/01/2003 at 3:15 PM the nurses' notes reveal that the resident was medicated for right leg pain. The resident was transferred to the hospital to rule out possible right hip fracture. (b) Further review of the clinical record of the nurses' notes for resident #41 indicates that the resident was readmitted to the facility on 8/06/2003 at 8:30 PM with the diagnosis of Pubic Rami Fracture S/P (status post) fall. The note continues that the resident is awake and confused with good vision and hearing. According to the progress notes dated 8/06/2003 the resident is alert and oriented times three, name, place and time. Mattress placed on the floor at bedtime, the bed is placed in the lowest position and a falling star is placed on the door. Further, the resident is unable to walk and requires total assistance for bed mobility and transfers. Review of the Fall Assessment dated 8/06/2003 the resident scored a "13" indicating that they are at risk for falls. Again, on 8/10/2003 at 3:00 PM the nurses' notes indicate that the resident was found on the floor upside down apparently trying to go to the bathroom. (c) On 10/31/2003 at approximately 3:30 PM the Director of Social Services was asked if the facility had investigated resident #41 falls and if they had any additional information regarding the resident's falls. The Director of Social Services stated that she would have to check. At approximately 4:30 PM the Assistant Director of Nurses (ADON) brought the piece of paper with the resident's name on it asking the surveyor what was needed. The ADON was asked if the facility had investigated the resident's falls and if they had any additional information. The facility has as yet not provided any additional information. 17. Review of the clinical record for resident #42 revealed that the resident was admitted to the facility with the following diagnosis! CVA, TIA, diabetes, blindness of right eye, HTN, GERD and AMS. Review of the Minimum Data Set (MDS) dated 8/2003/2003 indicates that the resident is independent for cognition and has no problems with short or long term memory. The MDS further reveals that the resident requires extensive assistance with one-person physical assist for bed mobility, transfers and ambulating in the room and corridor. The Fall 10 Assessment dated 7/28/2003 reveals that the resident scored a 12 indicating that they are at risk for falling. The Interim Plan of Care Fall Prevention dated 7/28/2003 indicates that under the heading "Risk for falls" and subheading "Elimination" the resident is checked "yes" for chair bound requires assistance with elimination. Some of the interventions identified are: orient to call light and keep in reach, ensure safe environment, drink in reach, PT (physical therapy) to screen, and Restorative Nursing evaluate for gait training. The Weekly Occupational Therapy Progress Summary dated 7/29/2003 indicates that the resident requires maximum assistance with ADL transfers (activities of daily living). (a) Review of the nurses' notes dated 8/17/2003 at 8:30 AM reveal that the resident was found sitting on the floor. After speaking with the physician the resident was sent to the hospital emergency room. The resident returned at 4:00 PM on the same day with an ice pack to the right upper arm. Further review of the nurses' notes dated 9/13/2003 at 10:00 AM reveal that the resident was found sitting on the floor by the Certified Nursing Assistant (CNA). The Fall Assessment dated 9/15/2003 indicates that the resident is at risk for falls. (b) The resident is Care Planned for being at risk for falls. The goal is that the resident will sustain no falls or related injuries thru 11/14/2003. Approaches/interventions ik listed are: call light within reach, monitor for environmental hazards such as clutter, furniture in path, make sure staff are aware of resident's potential risk for falls, instruct resident and caregivers to maintain bed in lowest position at all times and assist resident in safe transfer technique from bed to chair. The Weekly Occupational Therapy Progress Summary dated 9/9/2003 states that the resident requires supervision for ADL transfers. (c) On 10/31/2003 at approximately 3:30 PM the Director of Social Services was asked if the facility had investigated resident #42 falls and if they had any additional information regarding the resident's falls. The Director of Social Services stated that she would have to _ check. At approximately 4:30 PM the Assistant Director of Nurses (ADON) brought the piece of paper with the resident's name on it asking the surveyor what was needed. The ADON was asked if the facility had investigated the resident's falls and if they had any additional information. The facility has as yet not provided any additional information. 18. Review of the nursing progress note dated 8/9/2003 at 9:30 P.M. reveals that the Certified Nursing Assistant (CNA) called the Nurse to the randomly sampled resident #32's room. The note further states that the resident reported that he/she was trying to stand up but could not. The note at 11:30 P.M. 12 reports that the resident's left leg below the knee was swollen and painful to touch. The resident was sent to the hospital at 12 A.M. (a) Review of the 1 day Adverse Incident Report dated 8/11/2003 revealed that under the section "Outcome of Incident" none of the options were marked although the instruction given was to "please check". In addition, the section that states "Describe circumstances of the incident and what actions have been taken to implement the investigation-narrative should answers to basic to questions-who, what, where, and why" was also incomplete. The note reported that the randomly sampled resident #32, who is described as being confused, attempted to stand up from wheelchair, he/she loss balance and fell. Review of the adverse incident 15-day report for the randomly sampled resident #432 revealed that the resident was found with a fracture or disclosure of bones or joints on 8/9/2003. The report stated that the resident attempted to stand up from wheelchair and lost his/her balance and fell in his/her room. The resident sustained swelling to the left knee. The resident was described as having periods of confusion requiring extensive assistance with bed mobility, and total assist with transfers. There was no indication as to what actions were taken to implement the investigation and ensure that possible abuse was not involved. 13 19. Review of the 1-day Adverse Incident Report dated 6/12/2003 for sample resident #6 revealed that the resident sustained a fracture or dislocation of bones or joints with the resident being send to the hospital. According to the report, on 6/10/2003 the resident was found by a Certified Nursing Assistant (CNA) on the floor next to the bed, with a small raised area noted on the left eye. Review of the radiology report dated 6/10/2003 revealed that the resident sustained a sub-clinical fracture of the left hip with impaction at the fracture site. Review of the 15-day Adverse Incident Report revealed that the section under "Incident Information" for section D "Outcome of Adverse Incident (please check)" was left blank. Under the section "Analysis and Corrective Action" revealed that the apparent cause of the incident was described as the resident having a diagnosis of dementia and continues to exhibit periods of confusion. Under section B, the corrective or proactive action(s) taken is described as low bed in place and in lowest position, alarm mobility in place, call bell with in reach, and mattress placed on floor near bed at bedtime. Under section E the circumstances of the incident (who, what, where, when, and why) it was reported that the CNA found the resident on the floor next to the bed with small raised area noted on left eyebrow. However, the report failed to indicate when and why the incident took place and what actions were taken 14 to implement the investigation and ensure that possible abuse was not involved. 20. Review of the grievance for resident #33 filed on 5/20/2003 by the resident, revealed the resident stated falling during the night on 5/19/2003 while in his/her room. The resident stated a nurse was in the room and gave no assistance to the resident. The resident stated having bruises on both knees. The resident is coded on the MDS as moderately impaired and confused. The notes stated that an assessment cf the resident was done, revealing the redness. However, there was no investigation identifying the nurse or any other witnesses in an attempt to ensure that abuse was ruled out. 21. Review of a grievance filed on 6/12/2003 by the family for resident #35 revealed the resident fell and hurt his/her neck resulting in bruises. An assessment by the Abuse Coordinator resulted in staff indicating the resident "didn't fall". There was no further investigation as to how the resident obtained the bruises and there was no staff identified that relates to the situation. (a) Review of the facility's policy on Abuse and Neglect revealed the investigations are conducted solely at the discretion of the Administrator and the Abuse Coordinator. Interview with the Abuse Coordinator on 10/30/2003 at about 3:00pm, revealed that the grievances and Adverse Incident 15S Reports are reviewed by the Administrator and Abuse Coordinator. The Abuse Coordinator stated that if a preliminary assessment reveals no Abuse or Neglect, further investigation is not conducted and the incident is marked resolved. Interview with the Director of Nursing on 10/30/2003 at about 3:00pm, revealed all Adverse Incident Reports are documented and submitted to the Administrator and Abuse Coordinator for investigation and reporting to the proper governmental authorities. Based on evidence obtained during the survey, the facility failed to ensure that all alleged incidence of abuse, neglect, mistreatment and injuries of unknown origin was thoroughly investigated and appropriate actions taken to ensure residents' safety. 22. During the unannounced Licensure and Re-certification survey conducted on 10/27-31/2003 and based on resident, family, staff interview and record review, the facility failed to thoroughly investigate allegations of abuse and injuries of unknown origin to prevent further potential abuse while the investigation is in progress. The facility also failed to report the allegations of abuse, neglect and mistreatment to the proper State authorities for four (4) injuries of unknown origin and three (3) allegations of abuse (R #'s 13, 17, 29, 33, 34, 35, 36). Findings include: 23. Record review of the grievance for resident #36, filed by the resident's family on 6/30/2003, revealed that on 6/29/2003 at 9:00am, the resident was "pushed down on a shower chair and that a Certified Nursing Assistant (CNA) poured hot water on him/her." Family stated that the resident had two bruises with fingerprints under each arm, indicating that someone had held the resident too tightly. Further record review revealed on 7/2/2003, following the incident, an assessment was done by the Abuse Coordinator, revealing a discoloration the size of a dime under the resident's arm. There was no indication that the incident of alleged abuse was thoroughly investigated and what actions were taken regarding the CNA involved in the incident. Review of the resident's Minimum Data Set (MDS) revealed the resident to be severely impaired and unable to provide information regarding the incident. The facility failed to ensure that all alleged abuse were thoroughly investigated and reported to appropriate State authorities as required. In an interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, she revealed that after assessing the resident no further investigation was done and the CNA responsible was never identified. 24. Review of the grievance filed by the family for resident #34 on 6/23/2003, revealed a CNA was reported to tell the family member to buy the resident clothes that are easier to 17 use or the CNA is "bound to take off the resident's head one of these days". In addition, the grievance reported that this CNA had informed the family member to remove the resident's dolls from the closet because they were falling on her (CNA's) head. In a review of the investigation, the CNA was identified and was counseled on 6/24/2003. Review of the employee file for that CNA revealed the CNA has been switched from wing to wing in the facility because of other unsatisfactory related issues regarding her work ethics and attitudes. A review of the CNA's performance evaluation dated 9/25/2003, revealed "unsatisfactory" ratings in behavioral patterns and interpersonal relationships. During the survey, it was discovered the CNA was employed by the facility and on vacation at the time of the survey. The facility failed to ensure that the reported behavioral issue of this CNA was properly addressed with the CNA being sent from wing to wing instead of addressing the issues at hand. 25. Review of the grievance filed by resident #17, on 10/14/2003, revealed that the night staff are "rough" with him/her resulting in marks on his/her arms. Notes on the grievance form and interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, revealed that the resident was assessed by the Social Worker (Abuse Coordinator) and the marks did not appear to be a result by being grabbed. There was no further 18 investigation as to making any attempts to identify the CNA involved, with the grievance marked as being resolved. 26. Review of a grievance filed by a family member for Resident #29 on 8/5/2003, revealed that the family noticed marks on the resident's face. The family member also noted seeing two other resident's with similar marks on their face. The documentation revealed that the assessment done by the Abuse Coordinator revealed that the probable cause was the call bell clip being too close to the resident's face while the resident was sleeping. However, there was no indication that the grievance was appropriately investigated and was marked as resolved. There was no CNA's or staff identified as being interviewed or identified on the report. Interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, revealed that there was no further investigation done after it was assumed that the bruises were caused by the call bell clips. The other two residents, mentioned as having the same bruises, were never identified and there was no investigation/reporting done regarding their bruises. 27. Review of the clinical record for resident #13 revealed that according to the nurses' notes dated 10/20/2003 at 9:00 PM the resident was noted to be sitting in his/her bed in the low position with a mattress on the floor. The resident was found to have a "small laceration from unknown origin noted on 19 nose." The note continues that a 4x4 guaze was applied and that there was no further bleeding. The nurses' notes dated 10/21/2003 at 11:30 AM again mentions that a small laceration is noted on the nose. The physician was called and an x-ray was ordered. Further review of the clinical record reveals that an x-ray of the nasal bones was done on 10/21/2003. The report states " there is a cortical irregularity with destruction of the spine of the nasal bone.... ". The stated impression by the radiologist is a nasal bone fracture. However, the facility failed to investigate this injury of unknown origin and report to appropriate State agencies as required. 28. Review of the grievance for resident #33 filed on 5/20/2003 by the resident, revealed the resident stated falling during the night on 5/19/2003 while in his/her room. The resident stated a nurse was in the room and gave no assistance to the resident. The resident stated having bruises on both knees. The resident is coded on the MDS as moderately impaired and confused. The notes stated that an assessment of the resident was done, revealing the redness. However, there was no investigation identifying the nurse or any other witnesses. (a) There was also no indication that the alleged abuse was reported to appropriate State agencies as required. 29. Review of a grievance filed on 6/12/2003 by the family for resident #35 revealed the resident fell and hurt his/her 20 neck resulting in bruises. An assessment by the Abuse Coordinator resulted in staff indicating the resident "didn't fall". However, there was no further investigation as to how the resident obtained the bruises with no staff identified to ensure that any potential abuse is prevented. (a) A review of the facility's policy on Abuse and Neglect revealed the investigations are conducted solely at the discretion of the Administrator and the Abuse Coordinator. Interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, revealed that the grievances and Adverse Incident Reports are reviewed by the Administrator and Abuse Coordinator. The Abuse Coordinator stated that if a preliminary assessment reveals no Abuse or Neglect, a further investigation is not conducted and the incident is marked resolved. Interview with the Director of Nursing on 10/30/2003 at 3:00pm, revealed all Adverse Incident Reports are documented and submitted to the Administrator and Abuse Coordinator for investigation and reporting to the proper governmental authorities. However, further interview with the Abuse Coordinator revealed that none of the above incidents with the above identified residents were properly investigated and called into the Abuse Registry Hotline. The Abuse Coordinator stated that she was told by the Abuse Hotline personnel that they would not accept calls regarding "trivial" concerns. However, the Abuse Coordinator was not able to confirm this. 21 30. Based on the foregoing, Nursing Center at Mercy violated Title 42, Sections 483.13(3), and 483.13(4), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class I deficiency pursuant to Section 400.23(8) (a), Fla. Stat., which carries, in this case, an assessed fine of $15,000.00 This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). COUNT II NURSING CENTER AT MERCY FAILED TO IMPLEMENT WRITTEN POLICIES AND PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT, AND ABUSE OF RESIDENTS FOR THREE RESIDENTS Title 42, Section 483.13(c) Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code CLASS I DEFICIENCY 31. AHCA re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 32. During the unannounced Licensure and Re-certification survey conducted on 10/27-31/2003 and based on staff, resident interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents for three (3) residents. (R's #7, #49, and #51). Findings include: 33. At 6:55 pm on 10/30/2003 resident #49 was re-visited by this writer for a brief interview. The resident recognized 22 this writer by name and purpose of writer’s visit to the facility. The resident was asked if he/she had ever witnessed any abuse or neglect. The resident stated that he/she had not, but that "I can take care of myself”. (a) At approximately 7:05 pm resident #49 could be heard from the hallway calling out, "What do you want, what do you want". The resident continued to yell and scream, his/her voice getting louder and louder, "What do you want, why won't you answer me, what do you want". This writer looked into the resident's room, the resident was in bed, scooting to sit up and appearing to be frightened, he/she yelled again, "What do you want". The staff member in the resident's room was walking from the foot of the resident's bed, in between the bed by the door and bed by the window, the privacy curtain was pulled closed so that the resident in the window bed could not be seen. After the staff member glanced at this writer in the hallway and noticed that she was being watched, she began speaking to the resident. (b) Interview with the resident several minutes later revealed that he/she knows the staff member that she had been in his/her room the day before borrowing his/her adjustable table with his/her Certified Nursing Assistance (CNA), staff member #1. Staff member #1 spoke with resident #49, the resident described the staff member who was in his/her room and the staff #1 said she knew who it was, but did not know her name and would 23 try to find her. At approximately 7:35 pm, staff #1 reported that she could not find the staff person in question. (c) At approximately 7:30 pm resident #49 stated that the licensed nurse, staff #3, came into his/her room and wanted to know what he/she had told the state surveyor. Staff #3 stated that she (unknown staff member) was just making sure that the call bell was within his/her reach. The resident stated, "I'm really afraid, I am really afraid now, because he (staff #3) won't tell who the person is." (d) Review of the clinical record for resident #49 disclosed that a significant change assessment of improvement was completed on 10/1/2003. The resident was assessed as having an improvement in cognitive status, understands verbal information and is understood by others and has no moods or behaviors. (e) On 10/31/2003 at 6:00 pm, the social worker was interviewed regarding the investigation on the above incident. She stated, "I think they started an investigation, I am not sure". (f) At approximately 7:15 pm the social worker handed this writer several pieces of paper stating that this was the investigation regarding resident #49. The front page was hand written by the social worker, including a description of the incident as reported by the surveyor, "that she (surveyor) 24 observed a CNA near the resident's room, but left and did not talk to him/her and left him/her calling out 'What do you want, what do you want' and the surveyor felt that the CNA ignored the resident". The papers include written statements by the director of nursing, licensed nurse, and 2 CNA's. The 'Final Conclusion of Investigation' form showed that "No action taken, no one identified". However, there was no statement taken by the two people who witnessed the incident, the resident and this writer. Therefore, the facility failed to ensure that resident's concern and fear of reprisal was investigated thoroughly and appropriate actions taken in order to ensure resident's safety. 34. At approximately 7:00 pm on 10/30/2003 screaming and yelling in Spanish could be heard coming from the room of resident #51. The resident was observed in bed continuing to yell, while his/her roommate's television volume was blasting loud. The resident was pointing at his/her roommate through the privacy curtain, yelling. Several feet outside the resident's room was a certified nursing assistant (CNA). The CNA was asked to assist the resident, which she did, and turned down the roommate's television to an audible level. (a) The CNA was asked why she did not come to the assistance of resident #51 who could easily be heard screaming and yelling from the hallway. The CNA stated that there are 3 CNA's on the unit and that resident #51 is not her resident. The 25 CNA acknowledged that she heard the resident calling out for help. 35. On 10/29/2003 at 5:50pm, resident #7 was overheard to ask the Certified Nursing Assistant (CNA) in his/her room for some drinking water during the dinner meal observation. The CNA ignored this request and did not serve the resident water until prompted by the surveyor. The resident further stated that he/she does not receive drinking water with his/her meals. Based on observation and review of the Minimum Data Set (MDS), the resident is a bedfast resident and is not able to obtain liquids on his/her own. On the day of the observation, the resident's water pitcher and cups were located out of his/her reach. Further, the facility did not follow their hydration program for the 200 wing at the dinner meal, as the water pitchers (sent with the food carts) were not served to residents in accordance with facility's policy by ensuring that all = residents, especially dependent residents, are taking in adequate fluids. 36. During the unannounced Licensure and Re-certification survey conducted on 10/27-31/2003 and based on record review and staff and resident/families interviews facility failed to develop and implement an effective Abuse policy to prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident’s property. Findings include: 26 37. Review of the facility's abuse policy and procedures revealed “that the purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrence of mistreatment, neglect, or abuse of our residents". This will be done by: " Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent further occurrences". According to the Policy "Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate an incident investigation". Under VI Internal Investigation of Allegations and Response revealed that under section 1. "Once the administrator or designee determines that there is a reasonable cause for possible mistreatment, the administrator or designee will appoint a person to take charge of the investigation", and under section 5. revealed that "The person in charge of the investigation will update the administrator or designee during the process of the investigation. The administrator or designee will keep the resident or residents' representative informed of the progress of the investigation." However, the policy failed to indicate that all staff has the right to report all alleged abuse to the Abuse Hotline upon discovery. 27 38. Initial interview with Social Services Director/ Abuse Coordinator on 10/28/2003 at 1:35pm revealed that when she receives the complaints the situation is assessed by the Social worker, or the department where the grievance beiongs. Investigation is also done by employees, if it is determined that it was a willful intend to cause harm then Abuse hotline is called. The determination is made and discussed with Department heads during meetings or with Director of Nursing (DON) or Social Worker (SW). The Abuse Coordinator further stated she has been in this position since April 2003 and up to now has not called any abuse reports to the hotline. She also said that Adult Protective Services told her not to report any "trivial" things. Grievances were reviewed with the SW and she stated that they were investigated and would provide copies. A copy of a Policy provided by administrator as revised on 4/14/2003 was reviewed with the abuse coordinator during this interview and she stated that she had never seen that policy but she will give surveyor a copy of the policy in use. 39. On 10/30/2003 at 3:00 pm a meeting was held with the DON/Risk Manager, Abuse Coordinator, 2 State Surveyors and 1 Federal Surveyor. Interview with DON revealed that it is up to the abuse coordinator to make a decision along with the administrator regarding the investigation of abuse and the reporting. She assumed that the adverse incident reports had 28 been investigated and reported by the abuse coordinator. The DON supervises the risk management and submit reports to AHCA. 40. Interview with Abuse Coordinator revealed that she is responsible for writing the grievances, start an investigation, and for sending other staff to determine skin condition or medical assessment. If physical evidence is present, the resident are questioned with the name of abuser or people actually involved documented. In addition, during the investigation, the Abuse Coordinator reported that the resident is to be protected with the staff suspend for 3 days during the investigation. 41. Review of the grievance log on 10/28/2003 revealed that several allegations of physical, verbal and neglect had been filed but the facility did not implement the abuse policy with an investigation of possible abuse/neglect/mistreatment not conducted. 42. Review of a grievance filed on 5/20/2003, revealed resident #33 alleged that he/she fell during the night of 5/19/2003 while in his/her room. Resident also stated that the nurse was in his/her room and no assistance was given to him/her. There was no investigation of this incident, which was also verified by the Abuse Coordinator on 10/30/2003 at about 3:00pm. 29 43. Interview with resident #30 on 10/30/2003 revealed that several months ago around midnight he/she fell on floor from his/her bed and started screaming. Although there were two nursing assistants (male and female) in his/her room talking to each other, the resident's plea for assistance was ignored by both staff. The resident reported that finally after waiting for a several minutes, they finally helped him/her. In addition, the resident reported that he/she hit his head and complained of pain. The staff did give him/her Tylenol but they failed to examine him/her for any injury. Interview with the Abuse Coordinator on 10/30/2003 at about 3:00pm revealed there was no investigation done on this incident. (a) In another incident with resident #30, on 8/9/2003, it was reported that the resident attempted to stand up from the wheelchair, in the resident's room, lost his/her balance and fell. Left leg below knee area was reported as swelling. The resident was transferred to the hospital. According to incident report, the resident sustained a fracture or dislocation of bones or joints (left leg). (b) Interview with resident #30 on 10/30/2003 at 7:20pm, revealed that in the morning after breakfast he/she wanted to pick up some left overs from the floor, bend down from the wheelchair and fell. The resident stated not remembering that day. The door was open and staff heard when he/she said " 30 Ay me cai" (I fell). Roommate also spoke with the staff and they immediately came to pick him/her up and the resident was sent to the hospital. A telephone call to the family member was made on 10/31/2003 at 8:45am, but the phone was not longer in service. Interview with the Abuse Coordinator on 10/30/2003 at about 3:00pm, revealed that there was no investigation made regarding this incident. 44. Review of the grievances revealed that on 6/12/2003 a family member of unsampled resident #35 alleged that resident fell and hurt his/her cheek and had a bruise and the family was not notified about this injury. The Abuse Coordinator stated on 10/30/2003 at 3:00pm, that the staff did not know what happened. A telephone interview with a family member for resident #35 on 10/31/2003 at 1:05pm revealed that; "the resident had a very bad experience. It was awful and the resident also lost his/her dentures while in the facility." 45. Review of the grievance report revealed that on 6/23/2003 a relative of unsampled resident #34 alleged that a Certified Nursing Assistant (CNA) was verbally abusive and used derogatory language. During the first incident on 6/19/2003, the CNA told the resident's relative in Spanish "You better buy your mother house coats that are easier to use because I'm about to take off her head one of these days". On another time on 6/20/2003 the CNA told the relative to "remove the dolls from 31 the top of closet because they were falling on her head", and again on 6/22/2003 the same CNA wanted to have the resident to be by his/her bed at 4:00pm. The resident's relative was in the dining room feeding the resident until 6:00pm. When the relative was about to leave the facility they notified CNA that "I left resident in the room you can put it to bed when you can". The grievance report further states that the relative reported that they overheard the CNA's statement in Spanish that, "She's mistaken if she thinks I'm going to put her to bed at the time she wants". Furthermore, the report states that the family member feels that the other residents feel intimidated by this CNA with her verbally abusive attitude. The report adds that on a prior visit this relative observed same CNA feeding resident on a hurried fashion pushing the resident's heads and pushing the spoon full of food in side their mouth. At that time the family decided not to have this CNA caring for her relative as she found she lacked professional demeanor. Family wishes to remain anonymous for fear of retaliation. (a) Review of the CNA's personnel file revealed that on 12/13/2003 a written warning was given to CNA as a response to a family report to the Administrator that CNA has been very rough with a family member (no resident name included). As a result of the allegation made by the family member of resident # 34 on 6/23/2003, the facility completed a new written warning 32 documentation on 6/24/2003 and the decision made by facility was: " CNA has been switched from wing to wing because of other unsatisfactory related issues regarding her work ethics and attitude." Furthermore on 9/25/2003 a performance evaluation was completed for CNA and was placed on probation for the next 60 days with a note stating: If CNA do not improve in the next 60 days you will be subject to termination". CNA refused to sign the evaluation. Telephone interview with family member on 10/31/2003 at 3:00pm revealed that she did not want the CNA to take care of resident # 34 because she was rude and abrasive. Family also confirmed the allegations made to the facility on 6/23/2003. There was no indication that the facility investigated the allegation of abuse and took appropriate actions to ensure resident's safety. 46. On 6/30/2003, a family member for resident #36 alleged that on that prior weekend, the resident complained that he/she was pushed down on a shower chair and the CNA poured hot water on him/her. The complaint also revealed that: "Resident has two bruises with finger prints under each arm as someone handled him/her too tightly and he/she would like to have bruises investigated". A telephone interview, on 10/30/2003 at 7:30pm, with the family member who filed the grievance for resident #36, revealed that; "all people do not have the patience to do things or do their jobs, i.e. some nurses." In the morning of the 33 alleged incident, the resident sustained the bruises mentioned above. The family spoke with the Administrator and he did assure the family that it was not going to happen again. The family stated the “water was hot and the arms and shoulders of the resident were very red". The family stated not knowing the CNA's name. The family also added that the resident had 3 or 4 bruises (marks) between the elbow and the shoulders on both sides. The family stated never hearing anything regarding an investigation to this incident. An interview with the Abuse Coordinator on 10/30/2003 at about 3:00pm, also revealed no investigation was done identifying the CNA involved and the severity of the incident. 47. On 8/5/2003, a letter was sent to the Administrator by a family member of resident #29 alleging, "he/she found a bruise on the resident's face. This is not the first time that this happened. It happened before over the 4th of July weekend. After the first incident, the family saw 2 other residents in the 300 wing with similar bruises on their faces, coincidence perhaps". At the end of the letter the family wrote: "The first time no one got back to me regarding the problem. I will not accept that this time. I need an explanation if this was an accident, I need to know. I do not want to jump to conclusions but this cannot continue". Review of nurse’s notes, dated 8/5/2003 at 1:45pm, revealed that CNA found resident in bed with hematoma in "R" 34 eye. Pamily was notified and they will continue to monitor resident. (a) Interview with the family member for resident #29 on 10/31/2003 at 7:30pm, revealed that the resident was observed with the bruise on his/her eye and chin. The family spoke with the nurse who told her/him it was a reaction to medication. The family member did not believe it. The family also saw another resident in unit 300 with bruises that looked like the resident fell. The family met with the Social worker but she did not get back to him/her. The family stated that they were not given an explanation as to the cause of the bruise. The second time a bruise was noticed by the family, the administrator called the family and said the he assessed the situation and he feit that the bruises were caused by the clip on call bell. 48. On 10/14/2003, resident #17 voiced a concern and told the social worker, “at night, the staff are rough with him/her in the way they grab his/her arms. This resident stated that this is why he/she has marks on his/her arms". Review of the grievance revealed that: "SW notices some marks but they did not appear to the SW to be as a result of being grabbed by his/her arms as he/she was stating" Interview with resident #17 on 10/30/2003 at 7:45pm revealed that he/she had the nursing home bracelet on left wrist and the CNA grabbed him/her by arm and the bracelet got into skin which made him/her bleed. A nurse 35 went to the room and treated the wound. The resident stated he/she was taken to a room to meet with staff and they brought in four (4) CNAs for resident to identify which CNA had grabbed him/her. The resident said he/she was able to identify the CNA. The resident has not seen the CNA again and was told that CNA was fired. Review of the Minimum Data Set dated 8/10/2003 revealed that resident is coded as "2" for cognition but resident was also selected by the facility as an alert and oriented resident able to participate in the group meeting. 49. Review of the Adverse Incident Reports revealed that 3 allegations of injuries of unknown origin were not investigated or reported to the abuse registry by the facility. 50. Review of the 1-day Adverse Incident Report dated 6/12/2003 for sample resident #6 revealed that the resident sustained a fracture or dislocation of bones or joints with the resident being send to the hospital. According to the report, on 6/10/2003 the resident was found by a Certified Nursing Assistant (CNA) on the floor next to the bed, with a small raised area noted on the left eye. Review of the radiology report dated 6/10/2003 revealed that the resident sustained a sub-clinical fracture of the left hip with impaction at the fracture site. Review of the 15-day Adverse Incident Report revealed that the section under “Incident Information" for section D "Outcome of Adverse Incident (please check)" was left 36 blank. Under the section "Analysis and Corrective Action" revealed that the apparent cause of the incident was described as the resident having a diagnosis of dementia and continues to exhibit period of confusion. Under section B, the corrective or proactive action(s) taken is described as low bed in place and in lowest position, alarm mobility in place, call bell with in reach, and mattress placed on floor near bed at bedtime. Under section E the circumstances of the incident (who, what, where, when, and why) it was reported that the CNA found the resident on the floor next to the bed with small raised area noted on left eyebrow. However, the report failed to indicate when and why the incident took place and what actions were taken to implement the investigation and ensure that possible abuse was not involved. 51. Review of the nursing progress note dated 8/9/2003 at 9:30 P.M. reveals that the Certified Nursing Assistant (CNA) called the Nurse to the randomly sampled resident #32's room. The note further states that the resident reported that he/she was trying to stand up but could not. The note at 11:30 P.M. reports that the resident's left leg below the knee was swollen and painful to touch. The resident was sent to the hospital at 12 A.M. (a) Review of the 1 day Adverse Incident Report dated 8/11/2003 revealed that under the section "Outcome of Incident" 37 none of the options were marked although the instruction given was to "please check". In addition, the section that states "Describe circumstances of the incident and what actions have been taken to implement the investigation-narrative should answers to basic to questions-who, what, where, and why" was also incomplete. The note reported that the randomly sampled resident #32, who is described as being confused, attempted to stand up from wheelchair, he/she loss balance and fell. Review of the adverse incident 15-day report for the randomly sampled resident #32 revealed that the resident was found with a fracture or disclosure of bones or joints on 8/9/2003. The report stated that the resident attempted to stand up from wheelchair and lost his/her balance and fell in his/her room. The resident sustained swelling to the left knee. The resident was described as having periods of confusion requiring extensive assistance with bed mobility, and total assist with transfers. There was no indication as to what actions were taken to implement the investigation and ensure that possible abuse was not involved. Interview with the Abuse Coordinator on 10/30/2003 at 3:00pm, revealed no investigation was done. (b) On 7/16/2003, it was reported on an incident report that a CNA stated "while she was bathing resident #32 in bed, the CNA turned to pick up a towel next to the bed and at that time, the resident rolled over and slid on the floor. 38 Resident was transferred to hospital. A telephone interview with family member on 10/31/2003 at 8:55 am revealed that the resident was in this facility for 6 or 7 years. The family was notified by the facility immediately after the accident; however, does not remember if resident was taken to the hospital and is not aware of any investigation being done. Interview with the Abuse Coordinator on 10/30/2003 at about 3:00pm, revealed no investigation was done regarding this incident. 52. Review of the clinical record for resident #41 reveals that the resident was admitted to the facility on 7/22/2003 with the diagnoses of syncope and ASHD. According to the Nursing Assessment Summary dated 7/22/2003 the resident ambulates alone or with assistance. It also indicates that the resident is alert. Nurses! notes dated 7/29/2003 reveal that the resident is alert and oriented times three. Progress notes dated 7/22/2003 at 7:25 PM indicate that the resident is alert and oriented times three to name, place and time. A mattress was placed on the floor at bedtime and the bed is placed in the lowest position. The note further reveals that a falling star is placed on the resident's door. The resident is unable to walk by her/himself and requires total assistance for bed mobility and transfers. According to the Fall Assessment dated 7/22/2003 the resident scored a "9." According to the form a score of 10 or above indicates a risk for falling. 39 (a) Review of the nurses' notes dated 8/01/2003 at 2:40 AM state that the resident was found on the floor at bedside with the Certified Nursing Assistant at the resident's side. The resident is quoted as saying, "I was trying to go to the bathroom and I slipped." A hematoma was noted on the back of the resident's head. On 8/01/2003 at 3:15 PM the nurses! notes reveal that the resident was medicated for right leg pain. The resident was transferred to the hospital to rule out possible right hip fracture. (b) Further review of the clinical record of the nurses' notes for resident #41 indicates that the resident was readmitted to the facility on 8/6/2003 at 8:30 PM with the diagnosis of Pubic Rami Fracture S/P (status post) Fall. The note continues that the resident is awake and confused with good vision and hearing. According to the progress notes dated 8/6/2003 the resident is alert and oriented times three, name, place and time. Mattress placed on the floor at bedtime, the bed is placed in the lowest position and a falling star is placed on the door. Further, the resident is unable to walk and requires total assistance for bed mobility and transfers. Review of the Fall Assessment dated 8/6/2003 the resident scored a "13" indicating that they are at risk for falls. Again, on 8/10/2003 at 3:00 PM the nurses' notes indicate that the 40 resident was found on the floor upside down apparently trying to go to the bathroom. (c) On 10/31/2003 at approximately 3:30 PM the Director of Social Services was asked if the facility had investigated resident #41 injury and if they had any additional information regarding the resident's falls. However, she was unable to provide any information. At approximately 4:30 PM the Assistant Director of Nurses (ADON) brought the piece of paper with the resident's name on it asking the surveyor what was needed. The ADON was asked if the facility had investigated the resident's injury to ensure that it was not related to possible abuse, neglect and/or mistreatment and if they had any additional information. However, the facility failed to provide any evidence that an investigation was conducted to rule out possible abuse. 53. Review of the clinical record for resident #42 revealed that the resident was admitted to the facility with the following diagnosis' CVA, TIA, diabetes, and blindness right eye, HTN, GERD and AMS. Review of the Minimum Data Set (MDS) dated 8/2003/2003 indicates that the resident is independent for cognition and has no problems with short or long term memory. The MDS further reveals that the resident requires extensive assistance with one-person physical assist for bed mobility, transfers and ambulating in the room and corridor. The Fall 41 Assessment dated 7/28/2003 reveals that the resident scored a 12 indicating that they are at risk for falling. The Interim Plan of Care Fall Prevention dated 7/28/2003 indicates that under the heading "Risk for falls" and subheading "Elimination" the resident is checked "yes" for chair bound requires assistance with elimination. Some of the interventions identified are: orient to call light and keep in reach, ensure safe environment, drink in reach, PT (physical therapy) to screen, and Restorative Nursing evaluate for gait training. The Weekly Occupational Therapy Progress Summary dated 7/29/2003 indicates that the resident requires maximum assistance with ADL transfers (activities of daily living). (a) Review of the nurses' notes dated 8/17/2003 at 8:30 AM reveal that the resident was found sitting on the floor. After speaking with the physician the resident was sent to the hospital emergency room. The resident returned at 4:00 PM on the same day with an ice pack to the right upper arm. Further review of the nurses' notes dated 9/13/2003 at 10:00 AM reveal that the resident was found sitting on the floor by the Certified Nursing Assistant (CNA). The Fall Assessment dated 9/15/2003 indicates that the resident is at risk for falls with a score of 16. The resident is Care Planned for being at risk for falls. The goal is that the resident will sustain no falls or related injuries thru 11/14/2003. Approaches/ interventions 42 listed are: call light within reach, monitor for environmental hazards such as clutter, furniture in path, make sure staff are aware of resident's potential risk for falls, instruct resident and caregivers to maintain bed in lowest position at all times and assist resident in safe transfer technique from bed to chair. The Weekly Occupational Therapy Progress Summary dated 9/9/2003 states that the resident requires supervision for ADL transfers. (b) On 10/31/2003 at approximately 3:30 PM the Director of Social Services was asked if the facility had investigated resident #42 injury and if they had any additional information regarding the resident's falls. The Director of Social Services stated that she would have to check. At approximately 4:30 PM the Assistant Director of Nurses (ADON) brought the piece of paper with the resident's name on it asking the surveyor what was needed. The ADON was asked if the facility had investigated the resident's injury and if they had any additional information. However, the facility did not provide any additional information to indicate that this injury was thoroughly investigated to rule out possible abuse/neglect/mistreatment. 54. Based on the foregoing, Nursing Center at Mercy violated Title 42, Section 483.13(c), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class I deficiency pursuant to Section 400.23(8) (a), Fla. Stat., which carries, in this case, an assessed fine of $15,000.00 This violation also gives rise to a conditional licensure status pursuant to Section 400.23 (7) (b). COUNT III NURSING CENTER AT MERCY FAILED TO PROVIDE EVIDENCE THAT SUFFICIENT FLUIDS WERE PROVIDED TO TWO OF 23 SAMPLED RESIDENTS TO MAINTAIN PROPER HYDRATION AND HEALTH Title 42, Section 483.25(j), Code of Federal Regulations, incorporated by Rule 59A-4.1288, Florida Administrative Code (QUALITY OF CARE) CLASS II DEFICIENCY 55. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 56. During the unannounced Licensure and Re-certification survey conducted on 10/27-31/2003 and Based on observation, interview and record review the facility failed to provide evidence that sufficient fluids were provided to two (#7 and #9) of 23 sampled residents to maintain proper hydration and health. Findings include: 57. Chart review of resident #9 indicated an elevated BUN of 28 from labs obtained 10/14/2003 (normal is 6 to 20 mg/dl). This was an increase from a BUN of 17 mg/dl on 7/11/2003. While this elevation was noted in the 10/17/2003 Dietary progress report it was not addressed and interventions were not 44 recommended for this resident. Further chart review contained two potentially conflicting flush orders for the bolus tube feeding. One order read "Plush 50cc H2.0 before and after each bolus feeding" and the other read "Fluid 200 cc with H2,0 q 8 hours." These orders were both on the physician's order sheet of 8/28/2003 and had not been clarified by the facility. Both orders were indicated as followed/given on the resident's medication administration record (MAR) but the 400 wing charge nurse indicated on 10/29/2003 at 4 PM that he/she was intending to administer 250 cc total flush and further commented that the order was “a little confusing." The LPN further stated that he/she did not know how much other staff was administering because he/she was new on the unit and did not know the residents that well. (a) During the afternoon observation (4:15PM) on 10/29/2003 the 400 Wing charge LPN was questioned about the lack of drinking water at this resident's bedside. The LPN stated that this resident was on a feeding tube and did not receive oral liquids. Upon further investigation it was determined (with the assistance of the Director of Nursing) that this resident received nectar consistency liquid and should be provided with thickened water instead orally. During follow-up questioning on this matter with the facility Diet Technician (approximately 15 minutes later) he/she stated that this resident should have 45 thickened water at the bedside. The resident room was revisited at this time and there was no thickened water at the bedside. The Director of Nursing stated that because of the resident's cognitive status no water would be placed there but it would be at the Nourishment station. However, the Nourishment station was visited next and there was no thickened water found in the refrigerator at 4:35 PM. 58. On 10/29/2003 at 5: 50 PM resident #7 was overheard to ask the Certified Nursing Assistant (CNA) in his/her room for some drinking water during the dinner meal observation. The CNA ignored the request and did not serve the resident water until prompted by the surveyor. The resident further stated that he/she does not receive drinking water with any of his/her meals and must ask for water every day. The resident is a bedfast resident. On the day of the observation the resident's water pitcher and cups were located out of his/her reach. Further, the facility did not follow their hydration program for the 200 wing at the dinner meal as the water pitchers (sent with the food carts) were not served to residents in accordance with policy. 59. Based on the foregoing, Nursing Center at Mercy violated Title 42, Section 483.25(3), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II deficiency pursuant to Section 400.23(8)(b), Fla. Stat., which carries, in 46 this case, an assessed fine of $2,500.00 This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). COUNT IV ADDITIONAL FINE UNDER SECTION 400.19(3), Fla. Stat. 60. The Agency, in addition to any administrative fines imposed, may assess a survey fee. The fine for the 2-year period shall be $6,000, one half to be paid at the completion of each survey. DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, Nursing Center at Mercy shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit “A” CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Counts I through IV. B. Assess an administrative fine of $32,500.00 against Nursing Center at Mercy, and assess a $6,000 survey fee 47 pursuant to Section 400.19(3), Fla. Stat. on Counts I through Iv. c. Assess and assign a conditional license status to Nursing Center at Mercy in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2001). 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 for Health Care Administration, Lealand McCharen, Agency Clerk, 2727 Mahan Drive, Building #3, Mail Stop #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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 DER BY THE AGENCY. Néetson E. Rodney’ Assistant Genera] Counsel Agency for Health Care Administration 8350 N. W. 52nd Street Suite 103 Miami, Florida 33166 48 Copies furnished to: Diane Lopez Castillo Field Office Manager 8355 N.W. 53°? Street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 49 EXHIBIT “A” Conditional License License No. SNF1627096; Certificate No. 11022 Effective date: 10/31/2003 02/29/2004 Expiration date: 50

Docket for Case No: 04-000993