CY-UTS STATE OF FLORIDA wot es AGENCY FOR HEALTH CARE ADMINISTRATQQN 40 i ~8 Py hid AGENCY FOR HEALTH CARE ' ADMINISTRATION, & Sy: HES Aes ee Petitioner, AHCA No.: 2004001539 AHCA No.: 2004001540 Vv. Return Receipt Requested: 7002 2410 0001 4237 0515 SOUTHPOINT HEALTH CARE ASSOCIATES, 7002 2410 0001 4237 0522 LLC, INC., d/b/a SOUTHPOINT NURSING AND REHABILITATION CENTER, 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 Southpoint Health Care Associates, LLC, Inc d/b/a Southpoint Nursing and Rehabilitation Center (hereinafter “Southpoint Nursing and Rehabilitation Center”), 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 $12,500.00 pursuant to Section 400.23(8), Fla. Stat. (2003), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Southpoint Nursing and Rehabilitation Center pursuant to Section 400.23(7) (b), Fla. Stat. 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. Southpoint Nursing and Rehabilitation Center operates a 230-bed skilled nursing facility located at 42 Collins Avenue, Miami Beach, Florida 33139. Southpoint Nursing and Rehabilitation Center is licensed as a skilled nursing facility; license number SNF1507096; certificate number 11147, effective 02/12/2004 through 06/30/2004. Southpoint Nursing and Rehabilitation Center 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. Southpoint Nursing and Rehabilitation Center 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 SOUTHPOINT NURSING AND REHABILITATION CENTER FAILED TO PROVIDE GOODS AND SERVICES NECESSARY TO AVOID PHYSICAL HARM FOR 1 OF 23 SAMPLED RESIDENTS AND 2 OF 15 EXTENDED SAMPLED RESIDENTS CREATING AN IMMEDIATE JEOPARDY SITUATION TITLE 42, Section 483.13(c) (1) (i), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code (STAFF TREATMENT OF RESIDENTS) CLASS I DEFICIENCY 9. AHCA re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 10. During the unannounced Licensure and Re- certification survey conducted on 02/09-12/2004 and based on observation, record review and interview the facility failed to provide goods and services necessary to avoid physical harm for 1 of 23 sampled residents (#17), 2 of 15 extended sampled residents (#38 & 39) and one resident (R #37) observed bleeding during a supper meal. 11. At 2:30 PM on February 9, 2004 surveyors observed Resident #17 attempting to cross the = street at the intersection of 2™ Street and Collins Avenue - from the west to the east - in his/her wheelchair. At this time the resident was seen propelling himself/herself from the rear of a parked car on the west side of the road by pushing the wheelchair backwards with his/her legs. Approximately half way across Collins Avenue a wheel on the resident's wheelchair became caught in a rut in the street, and it was necessary for an unknown passerby to venture out into the intersection and assist the resident to the sidewalk. On subsequently attempting to cross 2™ street from the South to the North one wheel of the resident's wheelchair rolled off the sidewalk, and dropped approximately 1.5 inches into the grass and dirt. And once again it was necessary for a second unknown passerby to reposition the resident's wheelchair on the sidewalk after which the resident resumed propelling himself/herself forward along the sidewalk in a northerly direction away from the facility. 12. At approximately 3:00pm on 02/09/2004 a licensed practical nurse (LPN) was interviewed on the third floor of the facility. On asking the LPN where Resident #17 was at present she stated she was not sure. She clarified her comment by adding that the resident goes to the second floor patio to smoke and is authorized to leave the building "on his own." 13. Subsequent review of a current antipsychotic drug (Zyprexa) behavior monitoring record dated 01/30/2004 for 02/2004 documented that the resident was a "Danger to self" and "Anxious". Further, the 02/2004 MAR revealed the resident had refused the following medications for the periods indicated, namely: Paxil (an antidepressant that was to be administered daily) for eight of the last ten days; Elavil (an antidepressant that was to be administered three times a day) for eleven of the last 19 doses; Zyprexa (an antipsychotic that was to be administered twice a day) for eight of the last 17 doses (two additional doses had not been documented as being given or refused) ; Dilantin (an anti seizure medication that was to be administered daily) for five of the last seven doses (the other two doses had not been documented as being given or refused.) ; Neurontin (an anti seizure medication that was to be administered twice a day) for nine of the last 18 doses (another dose had not been documented as being given or refused.) Lipitor (a cholesterol lowering medication that was to be administered daily) for seven of the last nine doses. 14. Further review of Resident #17's clinical record revealed the resident had been initially admitted to the facility on 10/24/2003 at which time he/she had been diagnosed with diabetes mellitus and depression. A resident transfer form dated 01/06/2004 - completed by the attending physician (not the resident's Psychiatrist) at the time of the resident's transfer to a local hospital emergency room - lists the reason for the transfer as "suicidal attempt", with a diagnosis of "depression." Under the heading of "additional pertinent information", an entry states: "Dr. (physician's name) visited pt. today with order to send to (receiving facility) for evaluation. Re: pt. wants to kill (himself/herself) .” 15. Surveyor review of the "Progress Notes" written by nurses and dated 01/22/2004 revealed the following: (a) 5:20pm Resident readmitted to facility. (b) 10:30pm "Wandering to other resident's room in the 2 floor, safety provide." (ce) 10:45pm "Back on the floor in company of CNA (certified nursing assistant) with alcohol odor, agitated, aggressive, combative, refuse to go to bed, keep wandering to other resident's room.” (d) 11:05pm "Call placed to (physician's name)." (e) 11:10pm "(Physician's name) called back with order to give now Ativan 3mg (milligrams) , IM (intramuscularly) now. Order carried out & given." (f) 11:30pm "Rsd still agitated, still wandering to the 15* floor, plan to get out of the building. Safety provide. After all explanations given (he/she) decide to go to bed while on the floor get off the chair and sit on the floor all safety and help provide." 16. Nursing notes dated 01/30/2004 at 2:00am _ state: "While everything is quiet resident plan to get out of the floor, already told the CNA "I can go out since I know the combination to open the door" and to make sure he/she said it for CNA." 17. Nursing notes dated 02/06/2004 at 4:30pm describe the resident at "verbally abusive to staff" and cursing. 18. Review of the "Doctor's Progress Note" completed by resident #17's Psychiatrist reveals the resident appears anxious and depressed with rambling speech. The assessment further notes the resident is delusional and has decreased impulse control, judgment and insight. The resident is further described as depressed, sad and anxious. 19. Review of the "Elopement Risk Alert" found on the resident's chart revealed it had not been completed since the resident's re-admission on 01/22/2004. 20. During a discussion with the Administrator, the Director of Nursing (DON) and the Corporate Nurse at approximately 5:47pm on 02/09/2004, the facility asserted that the resident makes his/her own decisions, chooses to go out on his/her own, is not incompetent and makes their own decisions. The Administrator made the statement that there is nothing in the resident's background to indicate the resident is not safe to go out except for motor skill deficit secondary to traumatic brain injury, and that the facility is not a prison. Finally the Administrator stated that residents have a right to come and go as they please. 21. At this time the resident's history of falls from the wheelchair (on 11/15/2003 and 02/05/2004) was addressed and surveyors were told that the resident's falls occur when he/she "slips out of wheelchair trying to pick things up." 22. The DON stated that if resident was a wander risk the facility would have put a wander-guard on the resident and during the day the receptionist would monitor the resident. The DON further stated that sometimes the residents sunbathe in front of the building, and that the resident had not been identified as an elopement risk during assessment. "No one knew he left the building." 23. The Administrator, after being advised of resident's documented psychiatric concerns stated should a resident be at risk for elopement, or physically and mentally at risk for harm - they must be monitored and counseled. Finally that, residents who need monitoring cannot safely leave facility without a responsible party. 24. Upon completion of this discussion the Administrator issued a letter to the resident at 6:30pm on 02/09/2004 that said, "It has come to our attention that you left the facility and did not sign out, nor did you follow the physician orders, bringing a responsible party with you to insure your safety, therefore you must here on, sign out at the station, and have a person with you to insure your safety until a further notice. It is of the utmost importance that you follow these rules, as well as the physician's order. If you do not follow the above rules we will be force to issue a discharge notice due to Non compliance." This letter bore the signature of the Administrator and contained the witnessed signature of the resident by an unidentified witness. 25. During a meeting with the resident's Psychiatrist of record (who has known Resident #17 for ten years), the Administrator, DON, Corporate Registered Nurse and two surveyors at 11:30am on 02/10/2004 the resident's history was reviewed status post a four story fall resulting in a traumatic brain injury. The resident's current psychiatric condition was reviewed including the fact that the resident is paranoid and may attack someone if a threat were perceived. The resident was described by the Psychiatrist as isolating at times, having difficulty propelling the wheelchair and managing wheelchair at times. Resident is described as having a low frustration tolerance. Psychiatrist had no memory of resident being suicidal. Last time he saw resident self- propelling the resident was moving forward - not backward. 26. Review of the current and previous clinical record for Resident #17 revealed there was no- physical or occupational therapy assessment or documentation of any treatment. Interview with the rehabilitation director at approximately 3:15pm on 02/10/2004 revealed resident was not considered a candidate for services secondary to the length of his/her disability. The resident was evaluated and a new wheelchair was provided which had tumble guards because of the resident's "ballistic movements." 27. The facility did not reassess the resident for risk of elopement, ability to leave the facility safely or the resident's ability to safely smoke without supervision or protective equipment (smoking blanket) as recommended by the social worker until after surveyor intervention on 02/09/2004. 28. As the facility did not assess Resident #17's risk of elopement, his/her ongoing refusal of medication, the resident's motor capabilities, his/her safety awareness, his/her verbally abusive behaviors, ability to safely propel himself/herself in a wheelchair; the safety of his/her smoking; his/her suicidal ideations or mental state; or his/her risk of seizures; and as surveyors observed Resident #17 having considerable difficulty crossing a busy 10 thoroughfare it was decided the facility had not supervised a resident with known special needs, and had not adequately monitored Resident #17 who had been determined to be a known danger to him/her self it was determined the facility had not provided services necessary to avoid physical harm. 29. After a list of residents who leave the building was obtained from the facility, the records of 15 out of the 24 residents on that list were examined to determine whether or not they had the potential to be impacted by this facility practice. The following findings apply to two of those residents: 30. Review of the clinical record for resident #39 revealed the resident was admitted to the facility with diagnoses of depressive disorder, hypertension, and hypothyroidism. The clinical record contains five "Doctor's Progress Notes" from the resident's psychiatrist dated 01/19/2003, 02/2003, 08/25/2003, 9/25/2003 and 11/25/2003. All five notes describe the resident as having poor judgment; insight and impulse control and list the diagnosis "Major depression with psychosis." The nurses' notes for 12/22/2003 state the resident expressed suicidal ideation, stating: "I want to die." During an interview at 12:01pm on 02/12/2004 in the lobby of the facility, the resident stated he/she has gone out for walks whenever he/she wanted to with her rolling 11 walker. He/she stated the walks were "just around the neighborhood" and not to any specific destination. He/she stated that: "things have changed now." 31. Review of the clinical record for resident #38 revealed the resident was admitted to the facility with diagnoses of psychosis, senile dementia, depressive disorder, chronic obstructive pulmonary disease, and cerebral vascular accident. Review of the "behavior/intervention monthly flow record" dated 11/24/2003 for the period of December 2003 states the behavior being monitored is "danger to self." The resident's initial care plan has a check mark next to the pre- printed comment, "Unsafe wandering and exit seeking behavior will be decreased." The resident's medications include Zyprexa (an antipsychotic) and Paxil (an antidepressant). During interviews with two staff members on 02/12/2004 at 11:50am, on the second floor of the facility, both stated the resident does not go out. During an interview with the resident at 41:55am on 02/12/2004, the resident stated he/she does, on occasion (about every other week) go to the store down the block. He/she further stated he/she goes by himself/herself and does not tell staff he/she is going all the time. Resident #38 observed outside the front door of the facility smoking during the afternoon and evening of 2/12/04 as well as on other occasions during the survey. 12 32. At 5:35 PM on 02/11/2004 surveyors observed resident #R37 being wheeled through the corridor by staff. The resident's left hand was bleeding moderately with consistent venous flow. The nursing staff was observed to wheel the resident to his/her room. At this time the registered nurse on duty stated there were no bandages on the floor and that she had to call down to central supply to get some. 33. At 5:40 the resident, whose hand was still bleeding without any bandage or gauze placed on his/her hand, proceeded to eat his/her supper meal, which had been on a table in his/her room. The resident continued to eat his/her meal, while bleeding onto the Styrofoam cup from which he/she was drinking, until a nurse came to dress his/her finger at 5:51 PM after the surveyors requested intervention from facility management staff. 34. Based on the foregoing, Southpoint Nursing and Rehabilitation Center violated Title 42, Section 483.130(c) (1) (i), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, and Section 400.022(1) (I), Florida Statutes, herein classified as a Class I deficiency pursuant to Section 400.23(8) (b), Fla. Stat., which carries, in this case, an assessed fine of $10,000.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). _B COUNT II SOUTHPOINT NURSING AND REHABILITATION CENTER FAILED TO ENSURE THAT RESIDENT’S PAIN WAS APPROPRIATELY ASSESSED AND APPROPRIATE/EFFECTIVE PAIN MEDICATION GIVEN TO ENSURE THAT THE RESIDENT’S BONE PAIN WOULD SUBSTITUTE FOR ONE OF TWENTY THREE RESIDENTS (#7) Title 483.25, Code of Federal Regulations, incorporated by Rules 59A-4, 1288 and 59A-4.106(4) (aa), Florida Administrative Code (QUALITY OF CARE) CLASS II DEFICIENCY 35. AHCA re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 36. During the Licensure and Re-certification survey conducted on 02/09-12/2004 and based on observation, record review and interview it was determined that the facility failed to ensure that resident's pain was appropriately assessed and appropriate/effective pain medication given to ensure that the resident's bone pain would subside for one of twenty three residents (#7). 37. While observing medication pass on Station 1 at 9:18 AM on February 11, 2004 it was noted that Resident #7 requested a medication for pain. {A December 30, 2003 care plan documents that Resident #7 experiences bone pain and has cancer of the kidney.) On returning to the medication cart to get the pain medication (Percocet) the registered nurse reported that the medication was not available for administration. At this time the nurse walked over to the 14 nurses' station to discuss this issue with her colleagues and supervisor. Subsequent to learning that the medication was not available the medical director - who was sitting at the nurses' station - issued a verbal order for the registered nurse to administer Darvocet N 100 now and every 4-6 hours as needed until the Percocet was available from the pharmacy. Resident #7 subsequently received a dose of Darvocet N 100 at 9:40 AM on February 11, 2004. 38. On checking back with the resident at 11:16 AM on February 11, 2004 to see whether the pain had been relieved - and in the presence of the Assistant Director of Nursing and the consultant pharmacist - Resident #7, who appeared to be in pain based on his facial expression, stated that he was still in pain and that on a scale of 1 to 10 his pain was still at an 8. At this time the resident further stated that he had taken Darvocet N 100 before and that "Darvocet doesn't work" - i.e., Darvocet does not provide him with pain relief. The facility had failed to appropriately assess the resident's pain and his/her needs for pain medication to effectively relieve the pain as much as possible. 39. At this point the Assistant Director of Nurses was made aware by nursing staff that 12 doses of Percocet were available in the very same Emergency Drug Kit from which the nurse had obtained the Darvocet N 100. Furthermore the ADON 15 confirmed that had the resident received the Percocet that was available in the Emergency Drug Kit as his/her physician had ordered - rather than the newly prescribed Darvocet which the resident knew would not provide him/her with effective pain relief - he/she would not still be experiencing pain. 40. Based on the foregoing, Southpoint Nursing and Rehabilitation Center violated Title 42, Section 483.25, Code of Federal Regulations as incorporated by Rules 59A-4.1288, and 59A-4.106(4) (aa), Florida Administrative Code, and Section 400.022(1) (l), Florida Statutes, herein classified as a Class II deficiency pursuant to Section 400.23(8) (b), Fla. Stat., which carries, in 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 III ADDITIONAL FINE UNDER SECTION 400.19(3), Fla. Stat. 41. 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, Southpoint Nursing and Rehabilitation Center shall post the license in a prominent place that is in clear and unobstructed 16 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, II and III. B. Assess an administrative fine of $12,500.00 against Southpoint Nursing and Rehabilitation Center, and assess a $6,000 survey fee pursuant to Section 400.19(3), Fla. Stat. on Counts I, II and III. Cc. Assess and assign a conditional license status to Southpoint Nursing and Rehabilitation Center 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 (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 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 ORDER BY THE AGENCY. Netson E. Rodney Assistant General Counsel Agency for Health Care Administration 8350 N. W. 52nd Terrace Suite 103 Miami, Florida 33166 Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration 8355 N.W. 537? 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) 18 EXHIBIT “A” Conditional License License No. SNF 1507096 Certificate No. Effective date: 02/12/2004 Expiration date: 06/30/2004 19 11147

Docket for Case No: 04-001193