STATE OF FLORIDA 0 Lo fem AGENCY FOR HEALTH CARE ADMINISTRATION $ App 2 ‘ud . 7 ijy,. b; STATE OF FLORIDA A i). 1 on boys 22 AGENCY FOR HEALTH CARE Ky Ws ia ADMINISTRATION, EAB RE We Petitioner, vs. Case Nos. 2003008902 FI-WALDEMERE, LLC, d/b/a WALDEMERE PLACE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against Fl-Waldemere, LLC. d/b/a Waldemere Place, (hereinafter Waldemere), pursuant to §§ 120.569, and 120.57, Fla. Stat., (2003), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00, based upon one cited State Class II deficiency for Waldemere’s failure assure that a resident was free from unnecessary medications and able to attain his/her highest practicable physical, as well as mental well being. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2003). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Waldemere operates a 169-bed nursing home located at 2071 Waldemere Street, Sarasota, Florida 34239, and is licensed as a skilled nursing facility, license number 11350961. 5. Waldemere was at all times material hereto, a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.25())(1), Waldemere must ensure each resident’s drug regimen is free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences, which indicate the dose should be reduced or discontinued; or any combinations of these reasons. 8. On, or about, 11/20/03, the Agency conducted a complaint survey of Waldemere. 9. Based on resident record review, interview with staff and review of hospital admission records, it was determined that the facility failed to assure that one of seven sampled residents (Resident # 6) was free from unnecessary medications and was able to attain his/her highest practicable physical as well as mental well being. 10. Review of the medications being administered to resident by the facility were: Remeron 15 mg. daily, Trazodone 25 mg. daily, Ativan 1 mg. daily beginning on 08/23/2003 until discharge on 09/05/03, PRN (as needed) Ativan | mg., PRN Ativan 1 mg. IM (intramuscular) if PO refused, PRN Vicodin 5/500 mg. tabs 1 for moderate pain and 2 tabs for severe pain. 11. On 09/03/03, a Duragesic patch order was received for a 25 mcg/hr patch, which was applied. 12. Review of documentation from the "Emergency Room" showing her admission diagnosis as an overdose of Opioids. 13. Resident #7 was admitted to the facility on 07/17/03 with a diagnosis of HTN (Hypertension/High Blood Pressure), Parkinson Disease, Osteoarthritis, Dementia and Depression. 14. Review of medical record obtained from Sarasota Memorial Hospital on 11/20/03 at about 5:15 P.M. revealed the following documentation: 1. Admitted to the emergency room at 10:30 A.M. accompanied by daughter. 2. Patient is lethargic and appears dehydrated, multiple bruises noted. 3. 11:45 A.M. Labs drawa and sent to lab. 4. 11:50 A.M. 0.9 NS (normal saline) begun at 200 cc/hr to hydrate. 5. 1200 - Lab results returned diagnosing an overdose of Opioids. 15. Impressions: 1) Dehydration: Probably on the basis of altered mentation, possibly due to narcotic-induced somnolence and lethargy. We will approach conservatively as this woman has a very poor quality of life and would not be a candidate for aggressive care. Will hydrate with hypotonic saline and observe overnight. Will take off the Duragesic patch and control with oral pain medications if her pain should become out of hand. Follow-up electrolytes in the A.M. 2) Renal insufficiency: Probably a basis of dehydration and Bextra use. Hold off on Bextra and hydrate. 16. Review of the clinical record failed to find a complete plan of care, an initial Minimum ae Data Set (MDS), which was due on 07/31/03 so a care plan could be developed. 17. 18. Plan.” 19. The clinical record revealed: 1) Pain assessment addressing Osteoarthritis, dated on 07/17/03, on admission, which is incomplete. The document only contained a date, the resident's name, the diagnosis of Osteoarthritis, the medication for pain relief noted as Bextra and the assessors signature. 2) A preliminary care plan, completed on 07/17/03, on admission, contains two issues as being addressed. UTI (Urinary tract infection) and Osteoarthritis. The plan goals are for the Osteoarthritis pain to be controlled with the administration of Bextra daily (Bextra is a nonsteroidal anti-inflammatory medication). No other interventions were noted. The clinical record did not contain a completed, "Care Plan", only the "Preliminary Care Further review of the clinical record revealed that the resident was receiving several medications for pain, depression and anxiety. Medications orders include, but not limited to: 1. Remeron Sol, 15 mg. PO (by mouth) at HS (bedtime) to be dissolved in mouth (Remeron is a antidepressant). (Recommended dosages by "2003 Mosby's Nursing Drug Handbook" Geriatric dose is 7.5 mg. @ HS, may increase every 1-2 weeks to a maximum of 45 mg. a day.) 2. Trazodone, 25 mg. PO at HS, (Trazodone is a antidepressant). (Recommended dosages by "2003 Mosby's Nursing Drug Handbook" adult dose is 150 mg. daily in divided doses. May increase every 3-4 days for a maximum of 600 mg. daily.) 3. a) Ativan 0.5 mg. PO twice daily. b) Ativan 1 mg. PRN (as needed) every 6 hours PO. c) Ativan 1 mg. PRN every 6 hours IM (intramuscular) if PO refused. (Ativan is sedative given for anxiety.) (Recommended dosages by "2003 Mosby's Nursing Drug Handbook" Geriatric dose is 0.5 mg. to 1 mg. daily in divided doses or 0.5 mg. to 1 mg. @ HS.) 4. Vicodin 5/500 mg. PRN | tab for moderate pain and 2 tabs for severe pain (Vicodin is an Opioid used to control pain). Adult dose is 5-10 mg. every 4 hours. (Recommended dosages indications and interactions from "2003 Mosby's Nursing Drug Handbook" side effects to be alerted to are CNS (Central Nervous system) depression when used with other Opioids, sedatives or hypnotics.) 7. Duragesic 25 mcg/hr patch was ordered on 9/3/2003 and was in use prior to resident Icaving the facility on 9/5/2003. (Duragesic Patch is an opioid analgesic used for pain control.) (Recommended dosages, indications and interactions from "2003 Mosby's Nursing Drug Handbook.”) 8. Bextra 10 mg. daily PO (Bextra is a anti-inflammatory used to control pain of osteoarthritis.) (Recoramended dosages by "2003 Mosby's Nursing Drug Handbook.”) 20. Review of the Medication Administration Record (MAR) revealed that effects of medications being given were charted. However, not all medications administered were signed out on the MAR. Additional medications were given and signed out on the "Controlled Drug Record" and charted in the nurse's notes. 21. The resident record failed to reveal any monthly medication reviews conducted by the facility pharmacist for this resident. 22. Some routine medications consisted of: Bextra 10 mg. was given claily from admission to discharge. Remeron 15 mg. was given daily from admission to discharge. Trazodone 25 mg. was given daily from admission to discharge. Duragesic Patch 25 mcg/hr applied on 9/3/2003. Ativan 0.5 mg. PO twice a day from 8/23 through 9/5/2003. 23. Some PRN (as needed) medications consisted of: Ativan 1 mg. PO PRN was given: 14 days in July 11 doses, August 45 doses, 4 days in September 2 doses. Ativan 1 mg. IM PRN given: 14 days in July 2 doses, August 1 dose. Vicodin 5/500 mg. PRN 1 moderate pain, 2 severe pain was given: 14 days in July 20 tabs, August 84 tabs, 4 davs in September 7 tabs. 24. Review of "Behavior Monitoring/Psychoactive Flow Record" for August and September contain documentation of behaviors controlled with Ativan. It did not document which behaviors medications were being administered for. There was no record for the month of July. 25. Review of the nurse's notes for this admission finds daily charting with extensive documentation of episodes of anxiety and agitation being observed and medications being given to treat. 26. The notes reveal daily administration of PRN pain medications, but no documentation of the medication being requested by the resident other than on 7/24, 8/12, 8/16, 8/23, 8/28, 9/3 and 9/4/2003. 27. 28, The record also failed to reveal any pain assessments being completed. Nursing Notes: 8/11/03 1800 - "Was lethargic all day. No signs/symptoms of pain." 8/13/03 - "Medicated PRN for right shoulder pain with good effects also medicated x | for increased anxiety witia good effect." (Resident did not request PRN medications.) Medications given on 8/13/03 were: Routines, 2 mg. Ativan PRN and 1 tab Vicodin PRN. 8/16/03 2355 - "Pt complains of pain. Medicated with 2 tabs P.O. Vicodin 5/500.” Medications given on 8/16/03 were: Routines, 1 mg. Ativan PRN and 4 tabs Vicodin PRN. 8/20/03 7a/7p - "Pt very confused and extremely agitated early in shift. Ativan x 1 with good effects. Also Vicodin 1 tab P.O. for right shoulder pain with good effects.” (Resident did not request PRN medications.) Medications given on 8/20/03 were: Routines, 2 mg. Ativan PRN and 5 tabs Vicodin PRN. 8/21/03 7a/7p - "Med PRN for pain right shoulder with good effects also noted with increased anxiety. Ativan x 1 with good effects." (Resident did not request PRN medications.) 8/21/03 7p/7a - "Resident was very agitated after dinner crying out continuously... Ativan P.O. with good effect...resident calm and HS care completed." (Resident did not request PRN medications.) Medications given on 8/21/03 were: Routines and 2 mg. Ativan PRN 8/22/03 1920 - ....Pt very quiet; very slow to respond to verbal stimuli; facial grimacing noted. Administered Vicodin PRN per orders with good effect." (Resident did not request PRN medications. Medications given on 8/22/03 were: Routines, 2 mg. Ativan PRN and 2 tabs Vicodin PRN. 8/23/03 Ta/Tp - ..." Activities offered usually after lunch. Ativan PRN, which usually is effective. Pt freq. complains of right shoulder pain. Vicodin P.O. given with good 29. effects." (Resident did not request PRN medications.) Medications given on 8/23/04 were: Routines, 3 mg. Avan PRN and 5 tabs Vicodin PRN. 8/28/03 - 7a/7p - "Complains of right shoulder pain med x 1 for pain with good effects. Ativan x | for increase in anxiety with good effects." (Resident did not request PRN medications for anxiety.) Medications given on 8/28/03 were: Routines, 1 mg. Ativan PRN and 1 tab Vicodin PRN. 8/29/03 0900 - Seen and evaluated by MD. New orders received and carried out. Ativan .5 mg. P.O. BID (twice a day) due to increased episodes of agitation and or anxiety.” (Review of Behavior sheets and nursing notes fails to document support for these orders.) Medications given on 8/29/03 were: Routines which included the addition of 0.5 mg. Ativan PO twice a day, | mg. Ativan PRN and 2 tabs Vicodin PRN. For 21 days in August, 8/11/03 to 8/31/03, there were only 9 days of charted indications for PRN medications. The resident received, on average for those 21 days, 1.25 mg. PRN Ativan and 2.5 tabs Vicodin PRN daily. 30. Nursing Notes: 9/1/03 2140 - "Appears to be resting peacefully. No signs or symptoms of pain or discomfort. Flat affect.” Medications given on 9/1/03 were: Routines and 1 tab Vicodin PRN. 9/2/03 Ta/Tp - "Noted complaints of right shoulder pain during repositioning. Vicodin given at 8 A.M. and | P.M. with good effects." (Resident did not request PRN medications.) 9/2/03 5 p.m...... "Dr. called regarding new orders. Duragesic patch 25 mcg/hr every 3 days." Medications given on 9/2/03 were: Routines, 2 tabs Vicodin PRN and the addition of the Duragesic Patch 25 mcg/hr. Medications given on 9/3/03 were: Routines, | mg. Ativan PRN, 2 tab Vicodin PRN and Patch remains on. 9/5/03 - Resident out to Dr. _ office @ 8:30 a.m. Daughter with resident; resident alert to self only. AM care by staff prior to leaving for MD's appointment. Small abrasion noted to upper back region, skin otherwise intact, warm and dry to touch, all paperwork sent with daughter. Awaiting residents return.” 9/5/03 1300 - "Dr. office contacted regarding whereabouts of resident. Office advised resident left MD's office prior to lunch. Will continue to await return of resident. 9/5/03 1600 - "Resident st:Il has not returned from MD visit. MD office contacted again and was told they could not give caller (?) any information. Stated we must contact daughter. 9/5/03 1830 - "Received call from nurse @ SMH (Sarasota Memorial Hospital) regarding resident, asking for MAR'S to be faxed. Complied with request. Resident admitted to SMH room___ with Dx (diagnosis) of hyponatremia." 9/5/03 0000 - "Never returned to facility.” 9/6/03 1500 - "Call received from that my mother will not be returning to your facility. She is at Sarasora Memorial. Administration notified of phone call.” 31. The record failed to reveal any notations of other interventions offered to this resident to alleviate her agitation, anxiety or pain other than to medicate. 32. Interview with Director of Nursing (DON), Assistant Director of Nursing (ADON) and Medical Records Personnel failed to reveal any new information regarding this resident. 33. They were unable to answer any questions regarding the chart, the medications or the resident as she had been discharged prior to their employment at this facility. 34, Resident was discharged from Sarasota Memorial Hospital and admitted to different facility in the area. 35. The Agency determined that Waldemere has compromised the resident’s ability to maintain or reach his or his highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited these deficient practices as an isolated State Class II deficiency. 36. The Agency provided Waldemere with the mandatory correction date for this deficient practice of 12/20/03. 37. A State Class II deficiency subjects Waldemere to an administrative fine in the amount of $2,500.00. 38. Pursuant to § 400.23(8)(b}, Fla. Stat., the fine amount shall be doubled if the facility was previously cited for one or more Class | or Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. On 11/05/03, Waldemere was cited for two Class II deficiencies. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Waldemere, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2003), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2003). COUNT II 39. The Agency re-alleges and incorporates paragraphs (1) through (5), and (7) through (38) as if fully set forth herein. 40. | Waldemere has been cited for two or more Class IT deficiencies arising from separate surveys or investigations within a 60-day period, and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes. WHEREFORE, the Agency intends to impose a survey fee in the amount of $6,000.00 against Waldemere, a skilled nursing facility in the State of Florida, and conduct surveys every six months for two years, pursuant to § 400.19(3) (2003). Respectfully submitted this 3, Fla. Bar. No. 559334 Agency for Health Care Administration 525 Mirror Lake Drive, 330K St. Petersburg, FL 33701 727.552.1526 (office) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Lealand McCharen, Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE | HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail, return receipt no: 7002 2030 0002 7109 5530 on March ,31__, 2004 to Bart Wyatt, Registered Agent, Waldemere Place, 100 Second Avenue South, Suite 901S, St. Petersburg, Florida, 33701, and by U.S. Mail to Vicky K. Washington, Administrator, Waldemere Place, 2071 Waldemere Street, Sarasota, Florida, “A ; i 1) I) Le i4 Gerald L. Pickett Copies furnished to: Bart Wyatt Vicky K. Washington Gerald L. Pickett, Esq. Registered Agent Administrator Senior Attorney Waldemere Place Waldemere Place Agency for Health Care 100 Second Avenue South 2071 Waldemere Street Administration Suite 901S Sarasota, Florida 34239 525 Mirror Lake Drive, St. Petersburg, Florida 33701 (U.S. Mail) Suite 330K (Certified U.S. Mail) St. Petersburg, FL 33701 10

Docket for Case No: 04-001577