STATE OF FLORIDA ot AGENCY FOR HEALTH CARE ADMINISTRATION “43 g. AGENCY FOR HEALTH CARE ce ADMINISTRATION, Petitioner, vs. Case No. 2004002061 2004001318 ENGLEWOOD HEALTH CARE ASSOCIATES, LLC, d/b/a ENGLEWOOD HEALTHCARE AND REHABILITATION CENTER Respondent. ADMINISTRATIVE COMPLAINT COMES NOW, the AGENCY FOR HEALTH CARE ADMINISTRATION (“BHCA”), by and through the undersigned counsel, and files this Administrative Complaint against ENGLEWOOD HEALTH CARE ASSOCIATES, LLC, d/b/a ENGLEWOOD HEALTHCARE AND REHABILITATION CENTER, (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57, Plorida Statutes (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine and survey fee against Respondent, in the amount of eighteen thousand five hundred dollars ($18,500) pursuant to Sections 400.102(1) (a) and (d), and 400.23(8) (b), Florida Statutes (2003) [AHCA Case No. 2004001318]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2003) [AHCA Case No. 2004002061]. 3. The Respondent was cited for the deficiencies set forth below as a result of a survey conducted on or about February 2, 2004. JURISDICTION AND VENUE 4, The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2003). 5. Venue lies in Charlotte County, Division of Administrative Hearings, pursuant to Section 120.57, Florida Statutes (2003), and Chapter 28-106, Florida Administrative Code (2003). PARTIES 6. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for the licensure of nursing homes and enforcement of all 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 (2003), and; Chapter 59A-4, Fla. Admin. Code (2003), respectively. 7. Respondent is a nursing facility located at 1111 Drury Lane, Englewood, FL 24224. Respondent is licensed to operate a skilled nursing facility pursuant to license #SNF11440961. At all relevant times, Respondent was a licensed facility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. COUNT I RESPONDENT FAILED TO DEVELOP AND IMPLEMENT WRITTEN POLICIES AND PROCEDURES THAT PROHIBIT MISTREATMENT, NEGLECT, AND ABUSE OF RESIDENTS. Fla. Admin. Code R. 59A-4.1288(2003) INCORPORATING BY REFERENCE 42 CFR 483.13(c) (1) (i), (2003) CLASS I DEFICIENCY PATTERNED 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. On or about February 2, 2004, AHCA conducted a focused appraisal survey at Respondent’s facility. 10. Based on review of records, policies and procedures, and interviews with administration and staff, the facility failed to prevent neglect to 1 (Resident # 1) of 4 sampled residents. Three Licensed Practical Nurses (LPNs) on the night shift failed to recognize the necessity of initiating CPR and calling 911 for a resident, (who had full code status and, was alert and oriented minutes earlier), was found unresponsive; and by failing to coordinate staff on each shift who had knowledge of the individual residents to care for their needs; and by failing to have a designated charge person on duty to supervise those staff members on the weekend shifts. The facility failed to ensure the three LPNs on duty that night had received adequate reports concerning residents' status. The failure of these LPN's to demonstrate the appropriate response in this instance placed fifty (50) of the 117 residents in the building that night, who were full-code status, ina situation that was likely to cause serious injury, harm, impairment, or death in the event they were found unresponsive. Findings: Resident #1 was admitted to the facility on 1/15/04 with a diagnosis of Spinal Stenosis, Diabetes and Hypertension. The resident was alert and oriented with no indications of mental illness, dementia or terminal illness. The resident had been placed in the facility by "Children and Family Services" after monitoring revealed the resident could no longer care for himself at home. A review of the nurse's notes revealed that in the early morning hours of 1/25/04, at 4:50 A.M., Resident #1 was given his 6:30 A.M. diabetic medication Glyburide Tabs, 5 mg. The resident responded to his name and sat up on his right elbow to swallow the medication with a couple of sips of water, then stated, "Thank you", with no s/s (signs or symptoms) of distress at this time. A re-check of the resident at 5:00 A.M. found him unresponsive without vital signs. The LPN then went to the nurse's station to check the resident's chart for his code status and discovered he was a full code. She then asked a second LPN to come with her to validate the lack of vital signs. At approximately 5:10 A.M., the second LPN did, in fact, validate the lack of vital signs. At about 5:25 A.M., a call was then placed to the Unit Manager, at home, who was on call. She directed the LPN to notify the physician and family and get orders to have the body removed by the funeral home. The LPN did not tell the Unit Manager that the resident was a full code, CPR had not been started, and 911 had not been called. Documentation revealed that a physicians order to release the body was received at 5:20 A.M. The body was released to Lemon Bay Funeral Home at 6:30 A.M. according to the nurse's notes. In the course of several interviews with staff that took place between 1/28/04 and 2/2/04, it was revealed that on the night of 1/25/04 the facility had a staff member, who was scheduled to work the 7 P.M. to 7 A.M. shift, call off. In an attempt to cover this missing staff member, the Unit Manager arranged for an evening nurse to stay over until 3 A.M. and a day shift nurse to come in early 3 A.M. According to nurse "A", the agreement made between her and the Unit Manager when she agreed to work extra, was that she would be on her regular hall with residents who history she was familiar with. She is usually scheduled on the day shift on the "North" hall. A review of the schedule for the month of January validated her assignments to the "North" hall. The report she received at 3 A.M. on 1/25/04, according to the LPN, was not adequate and she had been assigned to unfamiliar residents. She stated that at 3 A.M. the facility did not provide a supervisor with whom to discuss this. The night shift (11 P.M. - 7 A.M.) on weekends lacks the same in-house supervision that is provided during the week (Sunday night through Thursday night). Although the resident was administered a dose of Glyburide at 4:45 AM, a review of Resident #1's MAR (Medication Administration Record) disclosed the medication was to be given as follows: 6:30 A.M. Accu check every day call MD if >200. 6:30 A.M. Glyburide (oral hypoglycemic agent) Tabs, 5 mg. one tab PO (by mouth) Q AM (every morning). Medication Administration Record notation noted the resident was a "Full Code.” A review of the social service notes for Resident #1 failed to document any Advance Directives being addressed. Areas on the form concerning Advance Directives remain blank. An interview with social services staff members on 1/28/04 at about 4:30 P.M. revealed the Advanced Directives had been addressed by social services with the resident and that literature had been left with the resident to read. The resident appeared unready to discuss the issues at that time. The Social Worker told the resident to let her know when he was ready to discuss these issues. The Risk Manager reviewed with the surveyor, chart audits completed at the beginning of this week (around 1/26/04) that identified other residents without code status on their charts. These records had been addressed and corrected. In- services had been conducted with the licensed staff. In a phone call to the facility on 1/29/04 at about 1:30 P.M., the Risk Manager was asked how many of the total residents (117) were a full code status on Saturday 1/25/04. A return phone call later the same day, revealed 50 of the 117 residents were full code status on 1/25/04 at 3 A.M. A review of additional clinical notes indicated that the resident had a short period (10-15) seconds of unresponsiveness while in a shower on 1/22/04. The physician had been notified, neuro checks had been ordered and completed with no further concerns. Written Statement from Nurse "A": Arrived on unit at 3 A.M. Assignment not as agreed upon with Unit Manager. Had a split assignment. Tried to keep my cool and adjust myself on how to best organize my time on this 1* time challenge, with a few pointers from co- workers and was helpful to tell me he would need his section of the cart (117-124) at about 5:15 A.M. for about 15-20 minutes. I flagged my MAR for the 6 A.M.’'s. Flagged only, not signed out. Since I am more familiar with NB Hall, having worked them on other shifts, I felt pretty comfortable that I would get me work done by shift change. I went to south and spoke with (Nurse "B") and she told me her usual routine when she would need the SB cart about 5:15ish so I flagged my SB MARS, again only flagging, not signing out. Now I felt some panic setting in wondering "how can I be in 2 places so far apart" I got a grip and continued. At approximately 4:45ish I was in the pantry checking for chocolate milk for meds. I heard loud coughing from 307 ( ) and the light was on. I went to check it out. He was having a hard time and I went to get him some cough medicine and to save steps also gave him his 6 o'clock medications - no problems. In between the coughing spells, [ heard Mr. (Resident #1) tossing and turning. I had not nursed him before, though noticed him on N hall with his jazzy, figuring he might be A&O. I went around the curtain and asked him "Mr. are you ok?" "Yes, [am ok." "I'll be back with your med.” "Ok." I reviewed his MAR and assumed (my mistake) that I'd get his 1 x day accu check a little later. Since it had been running under 200 (blood glucose level) and fairly consistent. I returned to his room, he was lying with eyes closed. Easily aroused to tactile/verbal approach - light put on - res. propped himself up on right elbow - took med. No problems. No s/sx of distress, though to me, color looking slightly jaundice. "I'm ok.” I left the room doing some 6 A.M. meds on SB hall at times sharing cart with Nurse "B." Nothing personal, I'm not comfortable sharing a cart and probable will not repeat that. There was only 1 cup of yogurt on the med cart. Most of the residents make a face or distasteful sound with it. I told (Nurse "B"), I'll try to find some applesauce. Went back to the pantry, none anywhere. About 5:15ish no answer in main kitchen, no time to walk there with this pt light was still on in 307A, with periodic loud coughing. 1 wanted to check on him again. Accu check machine available at this time. Honest mistake of wanting to do (2) things at once. was ok. Went behind curtain, announcing myself "Mr. (Resident #1)" "I'm going to." I stopped talking sensing immediately a problem. Turned his pull string light on, expiration very obvious. I did have my stethoscope on me - no AP no RP and no respirations. Unresponsive to verbal/tactile. Went to get___— (Nurse "B") for confirmation. In between I checked his status, (again a new res. for me) Full Code "Oh God.” (Nurse "B") and I get to room both in agreement vital signs absent. Called (Nurse "C”) to confirm also all 3 of us uncertain about calling 911 at this point (about 5:30ish). (Nurse "C") suggesting to call 911. We all said to call (Unit Manager) - call made with news and should we call 911. "No." Call to Dr ands get "Ok to release the body." Body and paperwork prepared. Niece notified in Maryland. Niece accepting of news with lots of emphasis on a "tin box." I told (Nurse "C") I would be late over there, I had to finish up here 4 or 5 meds left. He said, "ok" he'll start over on NB hall. Lemon Bay Funeral called after Dr. K. called back. Note: During an interview with the physician via telephone on 1/29/04 at about 12:40 P.M., the physician stated he had been notified by administration several hours after the death, in early afternoon he thought. He stated this was his first notification of the death and he had been told the resident had not been coded. He stated he was not called when the resident died. The nurse's written staterment continued: Regrouped myself to finish meds. Sometime in between I called Unit Manager back and let her know I had given Mr. (Resident #1) med before he expired and should I circle the MAR with initials and write on back on the MAR page. (Not circle as if it wasn't given, I could have done that without a call.) She was going to think about it and let me know when she got in (6:15ish). Then I went down to SA to help (Nurse "B") catch up if needed. She said, "She'd be ok." Returned to north about 6:15ish to finish up there. I feel this is a pretty accurate description of a hectic experience. [ will be more careful. Sincerely, (Nurse "A") A telephone interview was conducted with nurse "A" on 1/30/04 at 8:56 A.M. to 9:30 A.M. A summary of that conversation is as follows: At 3 A.M., she got report at the nurses station and learned she had to work 2 half halls. She tried to get organized by checking her MARs. She talked with Nurse "C" because they were sharing a medication cart. She further stated that she was not familiar with Resident #1 but had seen him about the facility in his jazzy chair. She was familiar with his roommate however. She went in room 307 to talk with the other resident because he was coughing. She left the room to get him some cough medicine and while she was at it, she also got the 6:30 A.M. medication for Resident #1 (Glyburide 5 mg.) since he was already awake. Afier administering the medications to both residents of that room, she then went to the pantry and heard continued coughing. When she went back in the room to check on the residents, she sensed something wrong with Resident #1 and pulled the curtain open and discovered that Resident #1 had expired. She went back to the nurse's station to check his code status and discovering that he was a full code, she went and got another nurse (Nurse "B") and "she came in with me and we assumed he was gone too long." "I felt no use to code him." She then notified her Supervisor, the Unit Manager by phone, of the resident's death. She did not tell her Supervisor that the resident was a full code status. Her Supervisor said not to call 911 but to call the physician and the family. She then called Dr.___at 5:20 A.M. - he called back and she told him the Resident #1 had expired. "I did not tell him the resident was a full code." Q: Did you at any time consider this resident to be a coroner's case? : Never entered my mind to call the coroner's office. : Who was in charge that night? : No supervisor that night in the building. All in charge of own areas. : Have you had the supervision course? : Yes, I took it in August of 2003. RH > A - AH -F : Do you have anything else you would like me to know? A: 1 was scared because I gave it early (his 6:30 A.M. medication without the accu check). I was not given a report regarding Mr. (Resident #1) and his previous episode of unresponsiveness. I felt my assignment set me up to fail, as I didn't know these residents. It was not the assignment I Had agreed to come in for. I was just doing them a favor and now look where I am. We were working as a team and I was extra just trying to be helpful. I was just not prepared to have an unfamiliar assignment.” Q: Why did you go back into the room a few minutes after giving both residents their medications? A: Iwent inbecause__ was still coughing and felt something was wrong with Mr. (Resident # 1) so I checked on him too. Q: Did you ever consider calling 911 and then canceling the call if needed? A: No Telephone interview was conducted with Nurse "B" on 1/29/04 at 10:40 A.M. A summary of that conversation is as follows: She was on A Wing and had both sets of keys. There was a narcotic error, we found it and signed off on the cart. Nurse "A" immediately began to pre-pour her meds. She seemed upset about her assignment and told me "I am going to do whatever I got to do to get this done." She just did not know how to organize her time with a split hall assignment. Resident #1 was on the 300 hundred hall - at 5:05 Nurse "A” told her that Resident #1 was dead. "She asked me to go with her. I grabbed by scope and went with her. "Yep" he was warm but he was dead at 5:07 A.M. "She said she had already pulled chart and he was a full code. "She had already checked the chart before she came to get me, she knew his code status already." "She did not tell me he was a full code until after we went to the room." "She got all crazy on me.” They then told a CNA to go "get other nurse.” By this time it was already 5:10 A.M." Q: Why didn't you call a code? A: “I did not call a code because she said he was already dead 10 minutes before she came and got me. " Q: Who was in charge that night? A: "Weare all in charge. But we call the Unit Manager or the Director of Nurses. No one is in charge, we call if we need something." Q: What happened next? A: "Nurse "A" called Dr. "K" and told him the resident had expired about 5:00 A.M. and asked, "Can we have an order to send him to the funeral home?" "She did not tell the doctor the resident was a full code." "Nurse "A" asked me to lie for her. As we were leaving that morning, she asked me to tell anyone who asked that the body was already cold when we found him. "She just kept saying she had just medicated him and she was scared.” Telephone interview was conducted with Nurse "C" on 1/30/04 at 4:48 A.M. A summary of that conversation is as follows: He went over to get keys for the med cart at about 5:15 A.M. or so and one of the nurses asked, "Where are the death notices?” He asked who died and was told Resident #1 had expired. He then asked, "Did you call 911?" and was told the resident was a full code but that the Unit Manager told them they didn't have to call a code. Q: "Did you call 911." A: "No, I told them to and I went back to my hall to attend the other residents." Q: "Who was in charge that night?" A: "We did not have a supervisor that night, there is only a supervisor during the week." Q: "Did you know you were in charge?" (He was the nurse on "a" hall who according to administration was the unwritten charge person on weekend night shift.) : "Tdo now." : "Have you had the supervision course for LPN's?” A Q A: "Yes, I took the course over a year ago." Q: "Were you familiar with Nurse "A?" A : "No, she had a split cart. Twenty (20) and 20 on each hall." I had very little contact with her." Q: "Were you called over to that side to assess this resident (Resident #1)?” A: "No, I just went over for the keys." Q: "Did you tell her nurse "A" to call 911?" A: "Yes and she told me she didn't have to, that she called the Unit Manager and she said she didn't have to.” Q: "Did she tell the Unit Manager that he was a full code?" A: "She said she did and that I was wrong, that she only had to call the doctor and send the body to the morgue." She said she didn't have to call 911. During an interview with the Risk Manager on 2/2/04 at about 9:15 A.M., the policy for staff response to an unresponsive resident was requested. The Risk Manager related that the facility did not have a specific policy to address that issue. He stated they follow the standard of practice. When he was asked what the standard of practice was, he responded, "Call 911 and initiate CPR." When speaking about the code status of the other residents, the 3 LPNs who were on duty that evening were asked how they knew the code status of each residents. All 3 LPNs responded that they didn't know the status of all their residents. They stated they would have to check the charts. They further stated that the charts 10 were marked with a red dot to indicate a DNR (do not resuscitate) status. Nurse "C" also stated that you would look for the yellow EMS (Emergency Medical Services) sheet that designates code status. The breakdown in nursing reaction to a critical incident, such as unresponsive Resident #1, demonstrates inadequate care and services to prevent neglect for residents expecting a full code response. By the end of the initial visit on 1/28, it was determined the immediate danger to residents has been sufficiently reduced to no actual harm with potential for more than minimal harm that is not immediate jeopardy. Policy and procedures had been reviewed and the facility had: 1. A successful code on Monday morning 1/26 involving newly in-serviced CNAs and nurses. 2. In-servicing of the licensed staff regarding responding to unresponsive residents. 3. Chart audits of 117 residents to ensure advanced directives had been addressed on all residents. 4. Medical error course had been completed by all licensed staff. 5. Had reviewed all MA's for the month of February to assure accuracy of medications and code status of each resident. 6. All MAR's with any diabetic checked or medications had been reviewed and checked back to the physician's orders. 7. Nurse "A" had been relieved of duty pending the facilities final investigation. 11. Respondent was provided a mandated correction date of March 2, 2004. 12. The above actions or inactions are a violation of Title 42, Code of Federal Regulations 483.483.13(c) (1) (1), (2003), incorporating by reference Rule 59A-4.1288, Florida Administrative Code (2003), which requires the facility to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and 11 misappropriation of resident property. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. 13. Pursuant to Section 400.23(8) (a), Florida Statutes (2003), the foregoing is a class I deficiency and as such, presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, sericus injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a Class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the ccrrection of the deficiency. 14. The agency shall assess a one-time fine in the amount of $6,000 for each facility that is subject to the six-month survey cycle, pursuant to Section 400.419(3), Florida Statutes (2003). 15. A civil penalty is authorized and warranted in the amount of $12,500, as this violation constitutes a “patterned” Class I deficiency. 16. Pursuant to Section 400.23(7) (b), Florida Statutes (2003), the Agency is authorized to assign a conditional licensure status to Respondent’s facility. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration requests the Court to order the following relief: a. Enter actual and legal findings in favor of AHCA; b. Impose a $12,500 civil penalty against Respondent ; c. Assess costs related to the investigation and prosecution of this case, pursuant to Section 400.121(10), Florida Statutes (2003); d. Assess the fine for the six-month survey cycle, pursuant to Section 400.19, Florida Statutes (2003); and e. Uphold the conditional licensure status pursuant to Section 400.23(7) (b) (2003); and £. Grant any other general and equitable relief as deemed appropriate. 13 % NOTICE ly | The Respondent is hereby notified that it lai sche ‘e3 request an administrative hearing pursuant to cect SE fi s69) Se Florida Statutes (2003). 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. Meteiand> >. ars Katrina D. Lacy, Esquir AHCA, Senior Attorney Fla. Bar. No. 0277200 Counsel for Petitioner 525-Mirror Lake Dr. N., #330G St. Petersburg, FL 33701 (727) 552-1525 (office) (727) 552-1440 (fax) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail Return 14 Receipt No. 7003 1010 0002 4667 0289, to CT Corporation System, Registered Agent for Englewood Health Care Assoc., 1200 South Sy : . : Be Pine Island Road, Plartation, FL 33324, dated on April DY; 2004. Katvina D. Lacy, Esqui lidih. LL ex Copies furnished to: CT Corporation System Registered Agent for Englewood Health Care Asso. 1200 South Pine Island Road Plantation, FL 33324 (U.S. Certified Mail) Michael Allen, Administrator Englewood Health Care & Rehab. 1111 Drury Lane Englewood, FL 34224 (U.S. Mail) Katrina D. Lacy AHCA ~ Senior Attorney 525 Mirror Lake Drive, Suite 330G St. Petersburg, FL 33701

Docket for Case No: 04-002041