(-099 MRL bie ee bad STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION (4 MAR 18 PM L: 08 AGENCY FOR HEALTH CARE . ADMINISTRATION, Petitioner, AHCA No.: 2004000724 AHCA No.: 2004000169 Vv. Return Receipt Requested: 7002 2410 0001 4237 3943 FORT PIERCE HEALTH CARE 7002 2410 0001 4237 3950 ASSOCIATES, LLC d/b/a FORT 7002 2410 0001 4237 3967 PIERCE HEALTH CARE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against 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 128-60, Florida Statutes, (2003) hereinafter alleges: NATURE OF THE ACTIONS 1. This ig an action to impose an administrative fine in the amount of $2,000.00 pursuant to Sections 400.23(8) (b), Florida Statutes [AHCA No.: 2004000169}. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No. 2004000724]. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. venue lies in St. Lucie County, pursuant to Section 400.121 Florida Statutes and Chapter 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to nursing home licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Fort Pierce Health Care is a skilled nursing facility located at 611 S. 13 Street, Fort Pierce, Florida 34950 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I FORT PIERCE HEALTH CARE FAILED TO PROVIDE ADEQUATE ASSISTANCE DEVICES FOR A RESIDENT. TITLE 42 SECTION 483.25(h) (2), CODE OF FEDERAL REGULATIONS SECTION 400.022(1) (1), FLORIDA STATUTES RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS III 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 8. Because Fort Pierce Health Care participates in Title XVIII or XIX it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. During two complaint investigations conducted on November 6, 2003 and November 7, 2003 and based on record review and interview a certified nursing assistant did not report to the nurse a statement Resident #2 made on 9/18/03. Resident #2 stated to the nursing assistant that day he/she was going to put himself/herself" on the floor. " Despite this statement by the resident, no additional supervision was provided to Resident #2. The findings include the following. 10. Review of the closed record for Resident #2 on 11/6/03 revealed the resident was 86 years old, wheelchair bound and had the diagnoses of: angina pectoris, difficulty walking, muscle disuse atrophy, hypertension, ischemic heart disease, nephritic syndrome, chronic airway obstruction, gout, coronary artery anomaly, multi infarct dementia. 11. The clinical record further revealed the following: Resident #2 had no history of falls (MDS 8/15/03). The Rap summary dated 8/11/03 documented the resident had only one risk factor for falls, the resident took an antidepressant drug daily, so fall prevention was not care planned. The MDS of 8/15/03 documented the resident needed the assist of one person for transfer, had no long or short term memory problems and was aware of person, place, and season. The nurses notes dated 9/18/03 documented the resident had " intermediate confusion." On 9/18/03 the clinical record documented in the nurses notes that the CNA stated the resident slid out of her wheelchair, the resident was found sitting on the floor and that earlier the resident had stated she was going to sit on the floor so she can go to bed. The family and doctor were notified on 9/18/03 of the incident, x-rays were ordered. On 9/19/03 the record documented the care plan team met and that the incident of 9/18 was isolated and that the resident would be monitored for a trend. On 9/19 the resident was transferred to the hospital after the facility received a fax from the x-ray company stating the resident had sustained a fracture 9/18/03. 12. Interview with the Certified Nursing Assistant caring for the resident on 9/19/03 revealed the following: The CNA stated that on 9/18/03 the resident never asked to go back to bed. The resident did state he/she was going to put herself on the floor at one point. The CNA stated the resident had never said this before. However, the CNA did not report this statement to a nurse or other supervisor, and no additional supervision was provided to Resident #2 despite the fact that Resident number #2 made this statement. When the CNA left the room and before the resident was found on the floor the CNA stated the resident was busy rummaging through his/her draw. When the CNA returned the resident was on the floor. 13. Review of Hospital record and ME report revealed the following: The emergency room record documented the resident stated in the emergency room on 9/19/03 " I fell off the bed and hurt my right thigh." The resident was hospitalized from 9/19/03 to 10/7/03 when the resident died of complications related to the fracture. 14. The mandated correction date was designated as December 7,2003. 15. On December 12, 2003, during a revisit due to the complaint investigations and based on observation, interviews and clinical record review, the facility failed to provide assistive devices to prevent falls for 1 out of 25 sampled residents (Resident #21). The resident was to have wheelchair and bed alarms. The staff did not turn the chair alarm on or use the bed alarm properly. Also the bed alarm was not working properly. The findings include were as follows. 16. On 12/10/03, Resident #21 was observed sitting in a wheelchair in the dining room on Emerald Wing at 2:30 PM with a chair alarm attached to the wheelchair with the switch in the “off " position. At this time, a CNA was asked why the chair alarm was not on and no explanation was provided. The chair alarm was then put "on" and beeped which indicated that the alarm was "on". On 12/11/03 at 12:30 PM, the resident was again observed in the dining room on Emerald Wing in a wheelchair with the chair alarm attached to the chair and again "off". The CNA was asked why the alarm was “off" and no explanation was given again. The alarm was turned "on" by the CNA and the Unit Manager was notified of both incidents at this time. The clinical record was reviewed and contained a nurses' note dated 10/28/03 stating, "Patient will have chair alarm to alert staff if potential for fall and will monitor patient closely to avoid any new falls". Also in the record was a current plan of care for the resident with an intervention for the resident's impaired mobility dated 10/28/03 that the resident would have an "alarm on wheelchair". Finally, a "Care Plan Review" dated 10/28/03 was completed in response to a fall that the resident had which indicated that the resident was to have "chair and bed alarms to be added to the plan of care". This form was signed by the DON and numerous other staff members. The Unit Manager was interviewed at this time and could not provide an explanation as to why the wheelchair alarm had been off on two separate occasions within two days. At this time, the Unit Manager and the surveyor entered the resident's room and found the resident in bed with the bed alarm "off" and the pad for the alarm which the resident was to be laying on placed at the resident's feet. Again, no explanation was provided as to why the bed alarm was off or why it was in the wrong position and not under the resident. The CNA was instructed by the Unit Manager to fix the bed alarm and while the surveyor was in the room, the CNA was unable to get the bed alarm to work properly (the alarm sounded continuously while on). 17. Based on the foregoing, Fort Pierce Health Care violated 483.15(e) (1), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code and Section 400.022(1) (1), Florida Statutes herein classified as a Class III violation pursuant to Section 400.23(8)(c), Florida Statutes, which carries, in this case, an assessed fine of $2,000.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7) (b), Florida Statutes. DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Fort Pierce Health Care shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “A” EXHIBIT “A” one) Conditional License 04 MAR 18 PH 4: 09 License # SNF 10040953; Certificate No.: Effective date: 12-12-2003 Expiration date: 11-30-2004 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Fort Pierce Health Care an administrative fine of $2,000.00 for the one (1) Class III deficiency in accordance with Section 400.23(8)(c) Florida Statutes. 3. Assess against Fort Pierce Health Care a conditional license in accordance with Section 400.23(7), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if applicable. 5. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). 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 10 Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. George D. Shirejian, Esq. Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 E. Tiffany Drive - Suite 100 West Palm Beach, Florida 33407 Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 It 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 8S. 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 \> day of _Feksvaty , 2004. Gedrge D. Shirejian, Esq. 12 STATE OF FLORIDA RIE a AGENCY FOR HEALTH CARE ADMINISTRATION al Fort Pierce Health Care Associates, LLC AHCA No.: 2004000724 94 NAR 18 PH 4: gg d/b/a Fort Pierce Health Care AHCA No.: 2004000169 Livi S| si¥ L - A t t ELECTION OF RIGHTS FOR ADMINISTRATIVE CompL Ain if! N ISTRAVYE PLEASE SELECT ONLY 1 OF THE 3 OPTIONS IE ARINGS An Explanation of Rights is attached. OPTION ONE (1) ___ Respondent does not dispute the allegations of fact contained in the Administrative Complaint and waives Respondent’s right to object or to be heard. Respondent understands that by waiving Respondent's rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) ___ Respondent does not dispute and Respondent admits the allegations of fact in the Administrative Complaint, but Respondent does wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time Respondent will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3) Respondent does dispute the allegations of fact contained in the Administrative Complaint and Respondent requests a formal hearing, pursuant to Section 120.5 7(1), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. Respondent’s 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. In order to preserve Respondent’s right to a hearing, Respondent’s original Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent’s selected option is not received by AHCA within twenty-one (21) days from the date of the Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. If Respondent is interested in discussing a settlement of this matter with the Agency, please also mark and check this block. ( ). SEND NO PAYMENT NOW -- REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL RESPONDENT RECEIVES A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address.) Respondent (Licensee) Address: License. No. and Facility Type: Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. Telephone: 850-922-5873. STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 04 te EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTES“? '8 pp P . 0g Vy uj} (To be used with Election of Rights for Administrative Complaint form Abiagis d VS Tp ee the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty- one (21) days from the date you receive the Administrative Complaint. Please make your election of the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A final order will be entered setting forth the allegations as being deemed admitted and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION 2. ‘If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Compiaint.), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. If the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent’s 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 disputed. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it. PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent’s original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent’s selected option is not received by AHCA within twenty-one (21) days from the date of Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. i ty fio

Docket for Case No: 04-000999