STATE OF FLORIDA . of 4: AGENCY FOR HEALTH CARE ADMINISTRATION “08 OPH NS on, AGENCY FOR HEALTH CARE ME ADMINISTRATION, Petitioner, AHCA No.: 2004005388 v. Return Receipt Requested: 7002 2410 0001 4237 1499 KEY WEST CONVALESCENT CENTER, INC., 7002 2410 0001 4237 1505 d/b/a KEY WEST CONVALESCENT CENTER, “ 0 3TH / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Key West Convalescent Center, Inc., d/b/a Key West Convalescent Center, Inc. - (hereinafter “Key West Convalescent Center, Inc.”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $110,000.00 pursuant to Section 400.23, Florida Statutes (2003), following the Moratorium imposed on May 27, 2004 (AHCA#2003007929), for the protection of the public health, safety and welfare, and $6,000.00 survey fee pursuant to Section 400.19(3), Florida Statutes (2003). JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes, and 28-106, Florida Administrative Code. 3. Venue lies in Monroe County, pursuant to Section 120.57, Fla. Stat. (2003), and Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities, pursuant to Chapter 400, Part II, Florida Statutes (2003), and Chapter 59A-4, Florida Administrative Code. 5. Key West Convalescent Center, Inc. operates a 120- bed skilled nursing facility located at 5860 W. Junior College Road, Key West, Florida 33040-4392. Key West Convalescent Center, Inc. is licensed as a skilled nursing facility license number 1265096, with an expiration date of January 31, 2005. Key West Convalescent Center, Inc. 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. cCoUNT_I KEY WEST CONVALESCENT CENTER, INC. FAILED TO ENSURE THAT THE POLICY AND PROCEDURE RELATING TO ABUSE AND NEGLECT WERE FOLLOWED AND THEREBY FAILED TO PROVIDE THE NECESSARY CARE BND SERVICES THAT WERE NEEDED IN ORDER TO PREVENT WOUND INFECTIONS AND PRESSURE SORES FOR TWO RESIDENTS AND TO PROVIDE APPROPRIATE AND TIMELY EMERGENCY ATTENTION FOR ONE RESIDENT IN NEED OF SUCH ATTENTION CREATING AN IMMEDIATE JEOPARDY SITUATION FOR OTHER RESIDENTS; THE FACILITY FAILED TO ADOPT, IMPLEMENT AND MAINTAIN WRITTEN POLICIES AND PROCEDURES GOVERNING SERVICES PROVIDED IN THE FACILITY INCLUDING SERVICES REGARDING ADVANCE DIRECTIVES; THE FACILITY FAILED TO DEVELOP, IMPLEMENT, AND MAINTAIN A WRITTEN STAFF EDUCATION PLAN WHICH ENSURES A COORDINATED PROGRAM FOR STAFF EDUCATION FOR ALL FACILITY EMPLOYEES Title 42, Sections 483.13(c) and 483.10(b) (8), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code; Rule 59A-4.106(2) & (4) & (5) &(6), Florida Administrative Code; CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. During the two complaint investigations conducted on 5/20-22/2004 and based on record review and interview the facility failed to ensure that the policy and procedure relating to abuse and neglect were followed and implemented, thereby resulting in the facility failing to provide the necessary care and services that were needed in order to prevent wound infections and pressure sores for two of five residents, Residents #3 and #7, and to provide appropriate and timely emergency attention for one resident in need of such attention, resident #4, creating an immediate jeopardy situation for other residents. 8. Resident #3 was admitted to the facility on 02/06/04 after hospitalization and hip surgery on 01/08/04 and subsequently re-operated on 01/18/04 and 01/20/04 at Lower Keys Medical Center. The resident had a diagnosis of infected wound of the right hip, bi-polar hemiarthroplasty, Parkinson's disease and compression fracture of the lumbar spine. (a) On 01/08/04, the resident had a right hip replacement at a hospital in lower Keys. Subsequently, thereafter, the resident developed an infection of the right hip and was hospitalized on 01/18/04 with a diagnosis of right hip infection, for which he was operated on that same day. The resident continued to have difficulty and had another surgical procedure performed on 01/20/04. On 02/03/04, the physician's progress notes indicates that the resident had a MRSA infection {methicillin resistant staphylococcus aureus). The resident was discharged with orders for Vancomycin (an antibiotic) 1 gram Intravenous (IV) every 24 hours for 4 weeks. He was discharged from the hospital admitted to the facility on 02/06/04 with a diagnosis of right hip infection. (b) A review of the resident's record on 05/22/04 at. approximately 9:00 am, revealed that the resident continued to have difficulty with the surgical wound as evidenced by the numerous notations regarding the lack of proper and prompt staff attention, which led to pain and development of oozing pus from the wound. The resident record reads as follows. (c) Resident was admitted on 02/06/04 at 7:00 pm with right hip infection with non-sanguineous (clear, slightly red discharge) drainage, sutures were intact. On 02/7/04 at 2:00 pm, the resident was sent to the ER for a triple lumen placement (a three line central access port to facilitate IV antibiotics.). Apparently this was not done on that date since there is a note at 3:15 pm which indicates that the hospital called and the resident will have a central line inserted the next day (02/08/04). There is no note in the record that the resident was taken to the ER the following day for the central line placement, however, on 02/11/04 the record references flushing the central line. (d) On 02/12/04 serous sanguineous drainage noted on pad, sutures appear loose and the wound incision line is not aligned. The notes states that there is approximately a y%" gap in some areas. The resident's physician saw the resident at 6:00 pm that evening but there is no documentation of his findings in the progress notes. On 02/15/04 at 6:30 am the nurse's notes describes a purulent (foul smelling) drainage from the right hip. The morning staff was asked to call the physician. There is no evidence that the doctor was called. On 02/18/04 at 2:00 am, the resident continues to have loose sutures with serous sanguineous drainage. Per note, "resident's doctor aware (02/12/04) ." (e) On 02/20/04 at 12:0 am, the white lumen on the central line is blocked, "large amounts of drainage noted, sutures remain loose, some wound closure noted." There is no evidence that the physician was informed. Later than day at 12:00 noon, "light serous sanguineous drainage with white exudates" On 02/22/04 sero-sanguineous drainage, but there were no signs and symptoms of infection. On 02/22/04 at 4:00 pm, “moderate amount of whitish drainage noted, surgical wound remains open and loose." The resident is still receiving Vancomycin IV but continues to have problems with the wound. (£) On 03/01/04 at 3:40 am the nurse's notes indicates that the resident appeared lethargic earlier, dressing change with discharge. At 10:00 pm, the record notes that the wound has an approximate 1" gap with sutures loosely threaded. There is no evidence that the physician was informed. However, at 4:00 pm an appointment was made to see resident's physician for post surgical care. (g) On 03/02/04 between "7:00 pm to 7:00 am" (no specific time given), "right hip saturated with yellow pus. There is no evidence that the MD was notified. The resident is still receiving IV Vancomycin. A review of the MAR (medication administrations record) on 05/22/94 at approximately 10:00 revealed that on 03/02/04 and 03/03/04, the resident did not receive the required dose because it was unavailable. There is no documentation that the resident's physician was notified. There are no labs ordered to evaluate the efficacy of the antibiotic in view of the resident's continuing difficulty with the wound. In fact, the Vancomycin was discontinued on 03/06/04 with no new orders for antibiotic therapy. On 03/12/04, the resident has a purulent drainage but there is no evidence that the physician was informed. On 03/15/04, 3 days after, the nurse called the physician's office at 2:00 pm for a "mild, yellowish drainage from the wound site with a slight odor." The nurse requested a culture and sensitivity of the right hip site. At 9:00 pm the record notes "wound has been seeping large amounts of bright yellow drainage that almost soak up entire bed pad. Day shift _ (name of staff) attempted to notify MD but received no return call." A review of the progress notes dated 03/16/04 indicates that the doctor ordered a culture and sensitivity test. (h) On 3/17/04 the culture and sensitivity test revealed a light growth proteus mirabilis (organism 1). On 03/18/04 light growth staphylococcus aureus (organism #2) and on 03/19/04, isolated MRSA. The lab results were faxed to the doctor's office on 03/20/04. On 03/22/04 the physician ordered Clindamycin 150 mg, one every 6 hours for two weeks. However, per the results of the culture and sensitivity test, Clindamycin is only effective on organism #2, staphylococcus aureus and will not respond to organism #1, the proteus mirabilis. (i) On 03/22/04 at 3:45 pm, the resident was given Tylenol 1000 mg for right hip pain. At 11:00 pm, "large amounts of beige colored discharge noted." On 03/27/04, at 3:00 am, the resident received Darvocet for right hip pain. After thoroughly searching the record, an MD order for Darvocet could not be found. On 03/29/04, again the notes states "large amount of beige (copious) drainage on old dressing and weeping out of wound site." No evidence that the physician was notified. The patient received pain medication but the name of the medication was not identified in the record. On 03/31/04, resident is complaining of pain to the right hip but is refusing pain medication. There is no evidence that the physician was notified. (j) On 04/03/04 at 9:00 pm, treatment done to right hip incision moderate amount of yellow drainage noted. On 04/04/04 at 9:00 pm, "dressing completely saturated with beige drainage (saturated abdominal pad)." On call MD was called on 04/05/04 at 3:30 pm. At 7:30 pm, still no call back from on call MD. On 04/08/04, orders received from resident's primary physician to discontinue Darvocet, however, there is no evidence of the initial orders to initiate this drug. On 04/10/04 at 3:30 pm, resident complains of right leg pain and notes describe, "patient continues with brownish-yellowish thick drainage from right hip." At 6:50 pm, on call MD was paged. The resident was transferred to hospital ER at 7:25 pm. (k) On 04/06/04 the wound culture and sensitivity identified heavy growth of gram-positive bacillus and light growth of proteus mirabilis. Results were faxed to the physician on 04/12/04, six days after the lab reports was received. On 04/05/04 the test identified Corynebacterium xerosis (organism #1) and Proteus mirabilis (organism #2). There is no record that the resident was on any antibiotic therapy at this time, however, there is an MD order on 05/04/04 to discontinue Levaquin, however, there is no physician order to start the drug. The MAR indicates that the resident was receiving Levaquin 750 mg from 04/17/04. (1) On 04/12/04, at 12:30 am "dressing saturated with pus." On 04/15/04 at 9:00am, resident found verbally unresponsive. Resident was taken to the hospital ER via ambulance. Resident returned from the hospital at 4:00 pm complaining of pain to right leg and was given Darvocet (pain medication). There is no evidence that the physician was notified. (m) On 04/16/04,at 1:00 am, “large amounts of greenish drainage" was noted. The physician was not notified. On 04/18/04 at 1:45 a.m., the resident was still complaining of pain. There is no indication that the resident received pain medication at this time. On 04/21/04, physician ordered padded dressings very 8 hours. On 04/24/04 at 4:00 pm, site "oozing yellowish cream pus." No evidence that the physician was notified. On 05/0604 at 1:00 am, "thick, yellowish cream discharge" was noted but only in minimal amounts. On 05/07/08 at 3:00 pm, "scant drainage." At 6:30 pm, resident had a temperature of 101.2 degrees Fahrenheit (normal is at 98.6) and was treated with Tylenol. On call MD was advised at this time. At 7:00 pm, resident's temperature was 100.3. (n) On 05/08/04 the resident sedimentation rate (a type of blood test used to screen for inflammation) was 140. The normal values are 0 -15. At 11:30 am, on call MD was advised of lab values, new orders were given for Levaquin (antibiotic) 500 mg to be given orally, every day. Resident to be seen in MD office that Monday (May 10°). On 05/10/04, the resident was admitted to the hospital with a diagnosis of infected right hip and on 05/21/04, the 10 resident had a removal of the right hip prosthesis and debridement of bone and soft tissue of right hip. {o) On 05/22/04, at approximately 2:30 pm an attempt was made to interview the Licensed Practical Nurse (LPN) who works on the same floor of the facility, which the resident was residing prior to his admission to the hospital. Her response was " he went to the hospital for his hip infection." At approximately 3:45 pm on that same day, the facility administrator was asked about this resident and he responded "My God! What is the big deal? S/He went to the hospital." The Director of Nursing (DON) was not available for comment and the nursing staff was unable to provide any further information on this resident. (p) A review of the resident's care plan dated 12/27/03 and most recently updated 02/19/04 revealed that the infected surgical wound is identified and the approaches are to monitor for openings and increases in non-blanchable redness (retain color), abnormal discharge and foul odors. Notify the doctor of abnormal; increase in warmth at incision and abnormal labs. Based on record review and interview, the facility failed to follow their own procedures by failing to take appropriate actions in a timely fashion to ensure that this resident's wound was not infected, which caused unnecessary pain and suffering and led to the resident's hip deteriorating and needing surgery on 05/21/04 for removal of the prosthesis. 9. Resident #7 (R7) was admitted to the facility on 04/05/04 after she hospitalization. The resident has a diagnosis of Congestive Heart Failure (CHF) , anemia, arterial cardio-vascular disease (ACVD), Degenerative Joint Disease (DJD) , Breast Mass, history of Urinary Tract Infection (UTI), Gastro Intestinal bleeding (GI) arthritis, generalized swelling and renal failure. The resident is incontinent of bowel and bladder with poor mobility. The resident care plan dated 06/02/03 and recently updated on 04/16/04 identifies the resident at being at-risk for skin alterations. Even after new pressure areas were identified, there was no further attempt to update the care plan to reflect the resident's condition. R7 developed 3 in-house, stage II ulcer (a partial thickness of skin layers either dermis or epidermis that presents clinically as an abrasion, blister, or shallow ulcer) pressure areas (04/17/04, 05/02/04, 05/12/04 and 05/14/04) and the staff failed to ensure that this resident, who was identified as high risk for skin alteration, was being routinely monitored. (a) A review of the nurse's notes dated 04/17/04 revealed that a stage II pressure sore of the left coccyx, measuring 1 cm wide and 1 cm long. On 05/02/04 a new stage Il pressure area measuring 3 cm wide and 2 cm long was 12 discovered on the resident's right buttock. On 05/12/04 there is a new indication of a reddened area (unstaged) on the left big toe. There is a physician's order dated 04/30/04 to treat the area, however, there is no other documentation in the record that can speak to the date of this new area and the staging. On 05/14/04 another new stage II pressure ulcer measuring 0.5 cm x 2cm was found on the back of the resident's right upper thigh. (b) A review of the facility's Skin Polzcy and Procedure reveals that “upon detection that a resident has alteration of skin integrity, the nurse will notify the rehabilitation and dietary department via written communication." Dietary was only notified of the 05/02/04 pressure area and a dietary assessment was completed 10 days later on 05/12/04. There is no evidence that the rehabilitation department was ever informed of the resident's condition. The policy also states that a Braden Scale (a tool for predicting pressure sore risk) would be completed and a care plan and Minimum Data Set (MDS) will be reviewed. There is no evidence that this was completed and a further review of the record revealed a blank Braden Scale form. (c) On 05/22/04 at 3:15 pm, the Registered Dietitian (“RD”) was interviewed regarding the lack of dietary interventions for the pressure sores that were identified on 04/17 and 05/14/04 and the reddened, unstaged 13 area on the left big toe. The Registered Dietitian (“RD”) was not aware that the resident had multiple pressure areas since admission. She was only aware of the 05/02/04 pressure area. (ad) The rehabilitation staff was not available for interview at that time. 10. Review of the clinical record for resident #4 revealed that the resident was re-admitted to the facility on 5/13/04 with the diagnosis of recurrent urosepsis, dysphasia, feeding tube and obtundation. According to the Resident Assessment-Data Collection Form dated 5/13/04 the resident is dependent on staff for all ADL's (activities of daily living). The form further indicates that the resident is non-verbal and is not oriented to time, place or person. The nurses' note dated 5/13/04 at 3:15 P.M. at the time of admission reveals that the resident's respiratory rate is 28 per minute (normal 12-20) and she/he has a slight wheeze. The resident responds to simple commands such as squeezing hands and blinking her/his eyes. Continued review of the nurses' notes on 5/13/04, 5/14/04 and 5/15/04 reveal that the resident has inspiratory and/or expiratory wheezing that are "raspy." Nurse's note dated 5/15/04 at 1:00 A.M. indicates that the resident's respiratory rate was 32 and the O02 sat (oxygen saturation) was 98% on room air. The next nurses notes dated 5/15/04 at 11:36 P.M. states that 14 the " Pt (patient) skin color appeared grayish/bluish in color. Unable to get O02 sat (oxygen saturation) or pulse. Hands appeared swollen & pale. Pt. felt clammy. Unable to hear breath sounds. CPR was commenced c (with) the assistance of (mame) RN, (name) LPN and (name) CNA (certified nursing assistant)." The notes continue: at 11:40, 911 called for assistance and arrived at 11:45 and took over pt. care. The resident's family was notified at 11:55 and (name) Physician Assistant was called at. 12:00 A.M. (a) Further review of the clinical record reveals a Designation of Health Care Surrogate dated August 7, 1992 designating by name a person as the resident's surrogate for health care decisions. A note in the resident's chart dated 3/30 and signed by the Social Services states: "As per niece, she does want CPR performed on (name of resident) ." Review of the face sheet reveals that the niece is the resident's health care surrogate. (b) Interview with a Licensed Staff member on 5/21/04 at 8:00 P.M. regarding the above incident on 5/15/04 at 11:36 P.M. revealed that this staff member (#3) along with another Licensed Staff member (#4) went into the resident's room to start an IV (intravenous). Staff member #3 stated that when they went to lift the resident higher in the bed, they noticed that the resident was grayish/bluish. She/he went to get the pulse oxyimeter; there was no pulse and no respirations. The resident's fingers were swollen and "kind of white” that wasn't normal. The nurse stated that she/he ran to get the resident's chart so that they could check the code status. The two staff members reviewed the chart and determined that the resident was not a DNR so they started CPR. Staff member #3 stated that she/he tried to hold the resident's head back while staff member #2 did chest compressions and a certified nursing assistant (CNA) breathed for the resident using the ambu bag. Staff member #3 further stated that 911 was called right after "we knew there was a problem and after the chart was checked." (c) Interview with Licensed Staff member #4 on 5/24/04 at 9:45 A.M. regarding the same incident revealed a different sequence of events. The Staff reported that this nurse was called by staff member #3 to assist with starting an IV on resident #4. Nurse #4 stated that she/he went downstairs and set up the supplies necessary to start the IV. Staff member #3 was already in the resident's room when staff member #4 walked in. According to staff member #4, staff member #3 was attempting to get an oxygen saturation reading on the resident and stated that she/he was unable to get a reading. Staff member #4 stated, " (name of staff member) look at the nail beds, they're cyanotic (blue)." Staff member #4 also stated that nurse #3 stated that the resident's color and respirations had been off during the shift. At this time the resident was breathing 2-3 breaths per minute. She/he than told nurse #3 to get a blood pressure cuff and the chart. Nurse #3 returned to the room with the resident's chart and began "flipping" thru it to determine whether the resident had a Do Not Resuscitate (DNR) order or not. (ad) Once it was determined that the resident did not have a DNR, nurse #4 told nurse #3 to cali 911. According to nurse #4 the resident had now stopped breathing. She/he than called out to several CNA 's who were standing at the nurses' station. She stated that she called to (CNA 's name, (staff member#5) to bring the crash cart. The CNA did not know what she was referring to so nurse #4 yelled the red cart. The code cart was brought into the resident's room by the sink. Nurse #4 stated that she/he was attempting to pull the headboard off the resident's bed to use as a backboard but was unable to. She/he than yelled over to the CNAs by the code cart to bring the backboard. Initially, the CNAs were not sure where the backboard was but did find it on the back of the code cart. Nurse #4 states that she/he had also asked for the two-way breathing mask. She/he stated that she/he could hear the drawers being opened and closed by the CNA looking for the mask. They couldn't find the mask so CNA #5 was sent to the second floor for the ambu (two way breathing mask). In the meantime, according to staff member #4 she/he and another CNA (staff member #6) were trying to get the resident on the backboard. When CNA #5 returned with the ambu another nurse from the second floor returned with her/him. This nurse found the ambu in the bottom of the code cart. Once the ambu bag was brought into the room, the oxygen tank could not be found to connect to the ambu. The oxygen tanks are attached to the side of the code cart. Staff member #4 started chest compressions while CNA #6 was breathing for the resident using the ambu. (e) Staff member #4 stated, "no one had a clue as to what was going on." She/he further stated that no one had training in CPR, nor knew where the supplies were and had never been in a code situation. It was also reported that the facility had never provided staff education or an in-service program regarding emergency procedure. When asked the time frame from the time the resident stopped breathing to the time CPR was initiated, the staff member stated "10 minutes due to all the fumbling around. It was neglect. She/he was dead before starting CPR." (£) Interview with Staff member #5 (a CNA) on 5/21/04 at approximately 8:15 P.M. regarding the above incident revealed about three of the CNA were standing at the nurses' station when staff member #4 yelled out to them 18 to get into the room. Staff member #4 than told this CNA to get the red crash cart. Once the cart was brought into the resident's room staff member #5 was told to go to the second floor to get the two-way breathing mask. Staff member #5 stated that she/he was not sure what this was so he/she kept repeating two way breathing mask up the elevator to the second floor so that he/she wouldn't forget. Once the staff member got the mask from the second floor she/he returned to the resident's room with another nurse from the second floor. This nurse once in the resident's room found the two-way breathing mask (ambu) in the bottom of the code cart. Staff member #5 states, when asked, that it was about 10 minutes from the time she/he was called into the room with the rest of the CNA s until the time the ambu bag was brought in. She/he further stated that staff member #4 was doing chest compressions and staff member #6 was breathing for the resident with the ambu bag. (g) During interviews with Licensed Staff members on 5/20/04 between 7:20 P.M. and 8:00 P.M. and again on 5/21/04 between 12:00 P.M. and 12:45 P.M. four out of five staff were either not sure what the procedure is during situation when residents are found to be in distress (such as not breathing); not aware of the DNR status of the resident's that they are caring for; or not sure of where the necessary emergency equipment is kept. (h) Review of the Emergency Services policy for residents not breathing or have no pulse, indicates that "it is the policy of the facility to provide and or coordinate emergency services and responses based on standards of professional practice and in accordance with executed advanced directives." Procedure # 2 of the policy further states that in the event that a resident has signs and or symptoms of medical distress, clinical care and services will be provided in accordance to their: physician orders, emergent needs, clinical circumstances and advanced directives. Procedure #3 of the policy states as follows: cardio-pulmonary resuscitation (CPR) and other emergency services shall be administered by appropriate staff unless otherwise indicated (such as in the event of an administrated Do Not Resuscitate [DNR] order) . 11. Review of the seventeen personnel files of either licensed staff members or CNAs revealed that only five had updated CPR cards. 12. Interview with the Director of Admissions in the presence of another surveyor on 5/21/04 at approximately 12:00 P.M. when asked who can do CPR she stated "any one certified in CPR." During an interview on 5/21/04 at 12:45P.M., the Administrator, in the presence of another surveyor, stated that he was told by nursing that CPR certification is automatically updated at the same time as the nursing license when he was asked if the facility 20 requires staff to have CPR cards. When asked if the Director of Nursing (DON) was aware of the resident's situation, he stated (name of DON) “not sure what she knows." 13. Title 42, C.F.R. Section 483.10(b) (8), states in pertinent part: The facility must comply with the requirement specified in subpart I of part 489 of this chapter relating to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual’s option, formulate an advance directive. This includes a written description of the facility’s policies to implement advance directives and applicable State law. Rule 59A- 4.106, Florida Administrative Code, states in pertinent part: Facility Policies (2) Each nursing home facility shall adopt, implement, and maintain written policies and procedures governing all services provided in the facility (4) Each facility shall maintain policies and procedures in the following areas: (a) Activities (b) Advance Directives 21 (S) Staff Education (a) Each nursing home shall develop, implement and implement a written staff education plan, which ensures a coordinated program for staff education for all facility employees. The staff education plan shall be reviewed at least annually by the quality assurance committee and revised as needed. (b) The staff education plan shall ensure that education is conducted annually for all facility employees, 14. In this case, the facility violated Section 483.10(b) (8) and Rule 59A-4.106 (2) &(4) &(5) &(6) by failing to ensure that the direct care and nursing staff were familiar and able to implement the facility’s policies and procedures, including the procedures regarding emergency situations such as when a resident stops breathing and CPR must be given. Moreover, the facility failed to provide training, instruction, and education to the staff so that they could carry implement the facility’s policies and procedures, including the policies regarding an emergency situation such as when a resident has stopped breathing. The failure of the staff to be able to implement the policies and procedures regarding an emergency situation, such as when resident #4 stopped breathing, may have contributed to resident #4’s unfortunate death due to the staff not initiating appropriate and timely interventions upon first discovering the resident's grave condition. The failure of the staff to implement the policies and procedures resulted 22 in residents # 3 and #7 not receiving the necessary care and services needed to prevent wound infections and pressure sores. 15. Based on the foregoing, Key West Conva escent Center, Inc. violated Title 42, Sections 483.13(c) and 483.10(b) (8), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, and Rules 59A-4.106 (2) &(4) & (5) & (6), Florida Administrative Code, resulting in the Agency imposing a Class I patterned deficiency which carries an assessed fine of $12,500.00. However, in this case, the Agency has doubled the $12,500.00 fine and has imposed an administrative fine of $25,000.00 pursuant to Section 400.23(8) (a), Florida Statutes (2003). Section 400.23(8) (a) requires that the fine for a Class I deficiency be doubled if the facility has been previously cited for one or more Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. The facility was cited for a Class II violation on 2/26/04 (AHCA #2004002850). This Administrative Complaint was served and the facility has requested a formal hearing. The facility was also cited for a Class II violation on 5/2/04 (AHCA # 2003002419). COUNT IT KEY WEST CONVALESCENT CENTER, INC. FAILED TO ENSURE THAT APPROPRIATE AND TIMELY CARE AND SERVICES WERE PROVIDED 23 DURING AN EMERGENCY SITUATION THAT COULD HAVE PREVENTED A RESIDENT’S DEATH 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 (QUALITY OF CARE) UNCORRECTED CLASS III 16. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 17. During the complaints investigation conducted on 5/20-22/2004 and based on interview and record review the facility failed to ensure that appropriate and timely care and services were provided during an emergency situation, that could have prevented a resident's death (#4), creating an immediate jeopardy situation for other facility residents. 18. Review of the clinical record for resident #4 revealed that the resident was re-admitted to the facility on 5/13/04 with the diagnosis of recurrent urosepsis, dysphasia, feeding tube and obtundation. According to the Resident Assessment-Data Collection Form dated 5/13/04 the resident is dependent on staff for all ADL's (activities of daily living). The form further indicates that the resident is aphasic and is not oriented to time, place or person. The nurses' note dated 5/13/04 at 3:15 P.M. at the time of admission reveals that the resident's respiratory rate is 28 and she/he has a slight wheeze. The resident responds to 24 simple commands such as squeezing hands and blinking her/his eyes. Continued review of the nurses' notes on 5/13/04, 5/14/04 and 5/15/04 reveal that the resident has inspiratory and or expiratory wheezing that are "raspy." Nurse's note dated 5/15/04 at 1:00 A.M. indicates that the resident's respiratory rate was 32 and the 02 sat (oxygen saturation) was 98% on room air. The next nurses notes dated 5/15/04 at 11:36 P.M. states that the " Pt (patient) skin color appeared grayish/bluish in color. Unable to get 02 sat (oxygen saturation) or pulse. Hands appeared swollen & pale. Pt. felt clammy. Unable to hear breath sounds, CPR was commenced c (with) the assistance of (name) RN, (name) LPN and (name) CNA (certified nursing assistant)." The notes continue: at 11:40, 911 called for assistance and arrived at 11:45 and took over pt. care. The resident's family was notified at 11:55 and (name) Physician Assistant was called at 12:00 A.M. (a) Further review of the clinical record reveals a Designation of Health Care Surrogate dated August 7, 1992 designating by name a person as the resident's surrogate for health care decisions. A note in the resident's chart dated 3/30 and signed by the Social Services states: "As per niece, she does want CPR performed on (name of resident)." Review of the face sheet reveals that the niece is the resident's health care surrogate. 25 (b) Interview with a Licensed Staff member on 5/21/04 at 8:00 P.M. regarding the above incident on 5/15/04 at 11:36 P.M. revealed that this staff member (#3) along with another Licensed Staff member (#4) went into the resident's room to start an IV (intravenous). Staff member #1 stated that when they went to lift the resident higher in the bed, they noticed that the resident was grayish/bluish. She/he went to get the pulse oxyimeter; there was no pulse and no respirations. The resident's fingers were swollen and “kind of white" that wasn't normal. The nurse stated that she/he ran to get the resident's chart so that they could check the code status. The two staff members reviewed the chart and determined that the resident was not a DNR so they started CPR. Staff member #3 stated that she/he tried to hold the resident's head back while staff member #2 did chest compressions and a certified nursing assistant (CNA) breathed for the resident using the ambu bag. Staff member #3 further stated that 911 was called right after "we knew there was a problem and after the chart was checked." (c) However, interview with Licensed Staff member #4 on 5/24/04 at 9:45 A.M. regarding the same incident revealed a different sequence of events. The nurse stated that she was called by staff member #3 to assist with starting an IV on resident #4. Nurse #4 stated that she/he went downstairs and set up the supplies necessary to start 26 the IV. Staff member #3 was already in the resident's room when staff member #4 walked in. According to staff member #4, staff member #3 was attempting to get an oxygen saturation reading on the resident and stated that she/he was unable to get a reading. Staff member #4 stated, " (name of staff member) look at the nail beds, they're cyanotic (blue)." Staff member #4 also stated that nurse #3 stated that the resident's color and respirations had been eff during the shift. At this time the resident was breathing 2-3 breaths per minute. She/he then told nurse #3 to get a blood pressure cuff and the chart. Nurse #3 returned to the room with the resident's chart and began "flipping" thru it to determine whether the resident had a Do Not Resuscitate (DNR) order or not. (d) Once it was determined that the resident did not have a DNR, nurse #4 told nurse #3 to call 911. According to nurse #4 the resident had now stopped breathing. She/he then called out to several CNAs who were standing at the nurses' station. She stated that she called to (CNA 'a name, (staff member#5)) to bring the crash cart. The CNA did not know what she was referring to so nurse #4 yelled the red cart. The code cart was brought into the resident's room by the sink. Nurse #4 stated that she/he was attempting to pull the headboard off the resident's bed to use as a backboard but was unable to. She/he then yelled 27 over to the CNA 's by the code cart to bring the backboard. Initially, the CNA 's were not sure where the backboard was but did find it on the back of the code cart. Nurse #4 stated that she/he had also asked for the two-way breathing mask. She/he stated that she/he could hear the drawers being opened and closed by the CN looking for the mask. They couldn't find the mask so CNA #5 was sent to the second floor for the ambu (two way breathing mask). In the meantime, according to staff member #4 she/he and another CNA (staff member #6) were trying to get the resident on the backboard. When CNA #5 returned with the ambu another nurse from the second floor returned with her/him. This nurse found the ambu in the bottom of the code cart. Once the ambu bag was brought into the room, the oxygen tank could not be found to connect to the ambu. The oxygen tanks are attached to the side of the code cart. Staff member #4 started chest compressions while CNA #6 was breathing for the resident using the ambu. (e) Staff member #4 stated, "no one had a clue as to what was going on." She/he further stated that no one had training in CPR, knew where the supplies were and had never been in a code situation. There has never been an in- service regarding emergency procedure. When asked the time frame from the time the resident stopped breathing to the time CPR was initiated, the staff member stated "10 minutes 28 due to all the fumbling around. It was neglect. She/he was dead before starting CPR." (f) Interview with Staff member #5 (a CNA) on 5/21/04 at approximately 8:15 P.M. regarding the above incident revealed about three of the CNA were standing at the nurses' station when staff member #4 yelled out to them to get into the room. Staff member #4 than told this CNA to get the red crash cart. Once the cart was brought into the resident's room staff member #5 was told to go to the second floor to get the two-way breathing mask. Staff member #5 stated that she/he was not sure what this was so they kept repeating two way breathing mask up the elevator to the second floor so that they wouldn't forget. Once the staff member got the mask from the second floor she/he returned to the resident's room with another nurse from the second floor. This nurse once in the resident's room found the two-way breathing mask (ambu) in the bottom of the code cart. Staff member #5 states when asked that it was about 10 minutes from the time she/he was called into the room with the rest of the CNA s until the time the ambu bag was brought in. She/he further stated that staff member #4 was doing chest compressions and staff member #6 was breathing for the resident with the ambu bag. (g) During interviews with Licensed Staff members on 5/20/04 between 7:20 P.M. and 8:00 P.M. and again on 29 5/21/04 between 12:00 P.M. and 12:45 P.M. four out of five were either not sure of the procedure if a resident is found to be in distress (such as not breathing), not aware of the DNR status of the resident's that they are caring for, or not sure of where the necessary emergency equipment is kept. (h) Review of the Emergency Services policy for residents who are not breathing or who have no pulse indicates that: "it is the policy of the facility to provide and or coordinate emergency services and responses based on standards of professional practice and in accordance with executed advanced directives." The policy further states under procedure #2 that in the event that a resident has signs and or symptoms of medical distress, clinical care and services will be provided in accordance to their: physician orders, emergent needs, clinical circumstances and advanced directives. Further procedure #3 of the policy states as follows: cardio-pulmonary resuscitation, (CPR) and other emergency services shall be administered by appropriate staff unless otherwise indicated (such as in the event of an administrated Do Not Resuscitate [DNR] order). 19. Review of the seventeen personnel files of either licensed staff members or CNA's revealed that only five had updated CPR cards. 20. Based on the foregoing, Key West Convalescent Center, Inc. violated Title 42, Section 483.25, Code of Federal Regulations, as incorporated by Rules 59A-4.1288, 30 and 59A-4.106(4) (aa), Florida Administrative Code, a Class I deficiency with an assessed fine of $12,5000.00. However, in this case, the Agency has doubled the $12,500.00 fine and has imposed an administrative fine of $25,000.00 pursuant to Section 400.23(8) (a), Florida Statutes (2003). Section 400.23(8) (a) requires that the fine for a Class I deficiency be doubled if the facility has been previously cited for one or more Class II deficiencies during the last annual inspection or any inspection or complaint invest:gation since the last annual inspection. The facility was cited for a Class II violation on 2/26/04 (AHCA #2004002850). This Administrative Complaint was served and the facility has requested a formal hearing. The facility was also cited for a Class II violation on 5/2/04 (AHCA # 2003002419). COUNT III KEY WEST CONVALESCENT CENTER, INC. FAILED TO ENSURE THAT SUFFICIENT NURSING STAFF AND CAN WERE AVAILABLE TO PROVIDE ADEQUATE CARE TO ALL OF THE RESIDENTS IN THE FACILITY, CREATING AN IMMEDIATE JEOPARDY SITUATION Title 42, Section 483.30(a) (1)&(2), Code of federal Regulations, as incorporated by Rules 59A-04.1288, and Rules 59A-4.106(4) (r) and 59A-4.108(3)and(4), Florida Administrative Code, and Section 400.23(3) (a), Florida Statutes (2003) (NURSING SERVICES) CLASS I 21. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 31 22. During the complaints investigation conducted on 5/20-22/2004 and based on observation and interviews the facility failed to ensure that sufficient nursing staff was available to provide adequate care to all of the residents in the facility, creating an immediate jeopardy situation. It was determined during the investigation that a lack of adequate staffing could have contributed to an infection and pressure for 2 of 5 residents (#3 and #7) and death of another resident (#4). 23. Review of the facility staffing for the two-week period from May 3, 2004 to May 16, 2004 revealed that the facility did not meet the minimum staffing requirements for Licensed Staff or Certified Nursing Assistants (CNA). Section 400.23(3) (a), Florida Statutes (2003), requires the minimum licensed nursing staffing to be 1.0 hour per resident per day and the minimum certified nursing assistant staffing to be 2.6 hours per resident per day. On 5/3/04 the facility had a census of 97 but only 92 hours of total nursing. On the following dates the following nursing hours were reviewed with a facility census of 96. The following dates also show the facility being below the minimum number of nursing staff: 5/6/04 88 hours, 5/7/04 92 hours 5/8/04 80.5 hours 5/9/04 88.50 hours 5/10/04 91.50 hours 32 24. Review of the CNA hours for the same time period revealed that the facility did not meet the minimum CNA hours of 2.6 hours per resident: 5/6/04 243.50 hours 5/7/04 234.00 hours 5/8/04 187.50 hours 5/9/04 194.25 hours 5/10/04 218.25 hours 5/16/04 248.25 hours 25. Review of the staffing board on 5/20/04 at 7:05 P.M. revealed that for Care Group 1 there was only one Certified Nursing Assistant until 11:00 P.M. There were 21 residents in that Care Group. This was confirmed with one of the staff members at this time. 26. During an interview with a staff member on 5/21/04 at approximately 8:05 P.M. the staff member was asked if she/he has ever seen "ghost staff." The staff member stated that she/he has seen staff come into the facility for the first time at 1-2:00A.M. The staff is there for a short time and then they leave, leaving the residents without adequate staffing to meet their needs. 27. At 8:10 P.M. during an interview with another staff member, the staff member stated that schedules and time cards are falsified right up to the Director of Nurses (DON). This staff member named five staff members who have been on the schedule but were not in the building that day. 33 28. During an interview with a staff member via phone on 5/25/04 at approximately 9:45 A.M., the staff member stated that staff members that are listed on the facility's daily staffing sheet are not always working on that day. On 5/16/04 another staff member was seen clocking into the facility between 12:00 and 12:30 A.M. The staff member stayed at the first floor nurses' station for about twenty minutes and than left. This staff member stated to interviewee that they had to fax staffing to the State everyday. Also on 5/16/04 the staff member stated that there was only one licensed staff member working on the first floor during the 7:00 P.M. to 7:00 A.M. shift. 29. At 12:45 P.M. on 5/21/04 the Administrator was asked in the presence of another surveyor if the CNA 's and Licensed staff that are orienting with staff members are included in the staffing numbers. The Administrator stated, "Yeah, do the regs state that you can't include?" This Surveyor responded that the regs refer to direct care staff. The Administrator than responded, "Well, the resident is getting two CNA 's now instead of one." 30. Review of the residents #3, #4 and #7's medical record revealed the facility's shortage of staff placed these and all other facility residents at greater risk for immediate harm. Resident # 3 did not receive appropriate and timely wound care treatment leading to an infection and 34 hipbone debridement surgery. Resident #4 was not provided with appropriate and timely emergency attention and he/she died in the facility. Resident #7 was not provided with appropriate wound care services resulting in multiple pressure ulcers while the resident was in the facility. 31. Based on the foregoing, Key West Convalescent Center, Inc. violated Title 42, Section 483.30(a) (1) &(2), Code of Federal Regulations, as incorporated by Rules 59A- 4.1288, and violated Rules 59A-4.106(4) (r) and 59A-4.108 (3) and (4), Florida Administrative Code, and Section 400.23(3) (a), Florida Statutes (2003),and the Agency has imposed a Class I widespread deficiency which carries an assessed fine of $15,000.00. However, in this case, the Agency has doubled the $15,000.00 fine and has imposed a total fine of $30,000.00 pursuant to Section 400.23 (8) (a), Florida Statutes (2003). Section 400.23 (8) (a) requires the fine to be doubled if the facility has been previously cited for one or more Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. The facility was cited for a Class II violation on 2/26/04 (AHCA #2004002850). This Administrative Complaint was served and the facility has requested a formal hearing. The facility was also cited for a Class II violation on 5/2/04 (AHCA # 2003002419). 35 COUNT IV KEY WEST CONVALESCENT CENTER, INC. IS NOT ADMINISTERED IN A MANNER THAT ENABLES IT TO USE ITS RESOURCES, THE LICENSED STAFF (NURSES) AND NO-LICENSED STAFF (CERTIFIED NURSES ASSISTANT), EFFECTIVELY AND EFFICIENTLY IN ORDER TO MEET THE NEEDS OF THREE OF FIVE RESIDENTS AND CAUSING AN IMMEDIATE JEOPARDY SITUATION FOR ALL OTHER FACILITY RESIDENTS Title 42, Section 483.75, Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code and Section 400.147(2), Florida Statutes (ADMINISTRATION) CLASS I 32. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 33. During the complaint investigations conducted on 5/20-22/2004 and based on interviews and clinical record review the facility is not administered in a manner that enables it to use its resources, the Licensed staff (nurses) and non- licensed staff (certified nursing assistants), effectively and efficiently in order meet the needs of three of five residents and well-being (#3, #4 and #7), causing an immediate jeopardy situation for all other facility residents. 34. Review of the clinical record for resident #4 revealed that the resident was re-admitted to the facility on 5/13/04 with the diagnosis of recurrent urosepsis, dysphasia, feeding tube and obtundation. According to the Resident Assessment-Data Collection Form dated 5/13/04 the resident is dependent on staff for all ADL's (activities of 36 Gaily living). The form further indicates that the resident is non-verbal and is not oriented to time, place or person. The nurses' note dated 5/13/04 at 3:15 P.M. at the time of admission reveals that the resident's respiratory rate is 28 per minute (normal range 12-20) and she/he has a slight wheeze. The resident responds to simple commands such as squeezing hands and blinking her/his eyes. Further review of nurse's note dated 5/15/04 at 1:00 A.M. indicates that the resident's respiratory rate was 32 and the 02 sat (oxygen saturation) was 98% (normal range) on room air. The next nurses notes dated 5/15/04 at 11:36 P.M. states that the " Pt (patient) skin color appeared grayish/bluish in color. Unable to get Ox2 sat (oxygen saturation) or pulse. Hands appeared swollen & pale. Pt. felt clammy. Unable to hear breath sounds, CPR was commenced c (with) the assistance of (name) RN, (name) LPN and (name) CNA (certified nursing assistant) ." The notes continue: at 11:40 P.M., 911 called for assistance and arrived at 11:45 and took over pt. care. The resident's family was notified at 11:55 P.M. and (name) Physician Assistant was called at 12:00 A.M. (a) Further review of the clinical record reveals a Designation of Health Care Surrogate dated August 7, 1992 designating by name a person as the resident's surrogate for health care decisions. A note in the resident's chart dated 37 3/30(no year provided) and signed by the Social Services states: "As per niece, s/he does want CPR performed on (name of resident)." Review of the face sheet reveals that the niece is the resident's health care surrogate. (b) During interviews with Licensed Staff members on 5/20/04 between 7:20 P.M. and 8:00 P.M. and again on 5/21/04 between 12:00 P.M. and 12:45 P.M. four out of five staff were either not sure of the procedure during situations when they find a resident in distress (such as not breathing) ; not aware of the DNR status of the resident's that they are caring for; or were not sure of where the necessary emergency equipment is kept. Further interview with licensed staff members on 5/21/04 between 12:10 P.M. and 12:30 P.M. and again on 5/24/04 revealed that they have received no in-services regarding emergency procedures such as CPR or on the crash cart. (c) On Licensed Staff member stated that the CNAs have never been shown a crash cart and Many have not worked anywhere other than in a nursing home. A CNA who was interviewed on 5/21/04 at approximately 7:30 P.M. stated that after this incident she/he had requested a day off in order to attend a free CPR class. The Director of Nurses denied the request. During an interview with the Business Office Supervisor on 5/21/04 at 1:50 P.M. she stated that the facility doesn't follow up on whether staff have updated 38 CPR cards. "It's up to them to bring a copy to me since it's not required." The facility failed to ensure that qualified staff was on duty at all shifts to ensure that during emergency situations appropriate and timely action can be taken. (d) Review of the Emergency Services policy residents who are not breathing or who have no pulse indicates that "it is the policy of the facility to provide and or coordinate emergency services and responses based on standards of professional practice and in accordance with executed advanced directives." The policy further states under procedure #2 of the policy that: in the event that a resident has signs and or symptoms of medical distress, clinical care and services will be provided in accordance to their: physician orders, emergent needs, clinical circumstances and advanced directives. Further procedure #3 of the policy states as follows: cardio-pulmonary resuscitation (CPR), and other emergency services shall be administered by appropriate staff unless otherwise indicated (such as in the event of an administrated Do Not Resuscitate [DNR] order). During an interview with Director of Admissions on 5/21/04 at 12:00 P.M. in the presence of another surveyor when asked what the meaning of "other emergency services" meant she 39 stated that, "I take it to mean CPR, sending the patient to the hospital." (e) Review of the seventeen personnel files of licensed staff members and CNA 's revealed that only five had updated CPR cards. (f£) Interview with the Director of Admissions in the presence of another surveyor on 5/21/04 at approximately 12:00 P.M. when asked who can do CPR stated "any one certified in CPR." During an interview on 5/21/04 at 12:45 P.M., the Administrator, in the presence of another surveyor, replied that he was told by nursing that CPR certification is updated at the same time as the nursing license when he was asked if the facility requires staff to have CPR cards. During an additional interview at 3:20 P.M. with the Administrator regarding resident #4, the Administrator stated that Children and Family came to investigate on the night of 5/15/04. He states that he read the resident's chart and "is not aware of anything out of the ordinary." When asked if the Director of Nursing (DON) was aware of this situation, he stated (name of DON) "not sure what she knows". The facility's failure to ensure that direct care staff are familiar with the facility's policy and aware of their role during an emergency situation may have contributed to the resident's unfortunate death due to not initiating appropriate and timely interventions upon 40 first discovering the resident in a serious condition, which also place all other facility resident in an immediate jeopardy situation. 35. Review of resident #3 clinical record revealed that he/she was readmitted to the facility on 02/06/04 with a diagnosis of right hip infection. The resident had surgery on 01/18/04 for a right hip replacement and further surgery was performed on 01/18/04 and 01/20/04 for right hip infection. The resident continued to experience difficulty with his care and was eventually readmitted to the hospital on 05/10/04 and the right hip prosthesis was removed on 05/21/04. (a) A veview of the record dated 02/12/04 revealed that the resident wound was draining and the sutures were loose with misalignment of the incision. on 02/15/04 the record revealed a purulent 9foul smelling) drainage form the wound site. On 02/20/04, the notes reveal a large amount of drainage and the surgical wound remains open and loose. On 03/02/04 "right hip saturated with yellow pus." On 03/12/04 the resident had a purulent discharge and on 03/15/04, the resident had a mild, yellowish drainage from the wound site with a slight odor. At 9:00 pm that day, the wound discharge was described as "large amounts of bright yellow drainage from the wound site with slight odor." 4] (b) A wound culture and sensitivity test Gone on 03/18/04 identifies two organisms proteus mirabilis (organism 1) and staphylococcus aureus (organism 2). On 03/22/04 the physician orders Clindamycin however it is only effective on organism #1 but ineffective for organism #2. On 04/04/04 the nurse's notes reveal that the "dressing was completely saturated with beige drainage. On 04/04/04 another wound culture and sensitivity was done and a heavy growth of gram-positive bacillus and light growth of proteus mirabilis was identified. The Medicine Administration Record (MAR) indicates that the resident was receiving the antibiotic medication, Levaquin 750 mg but after thoroughly researching the resident's record, there was no evidence of a physician order for the drug. On 04/10/04 at 3:30 pm, the resident complains of right leg pain and the notes describe, "patient continues with brown-yellowish thick drainage from right hip." On 04/12/04, the notes stated, "dressing saturated with pus." (c) On 04/15/04 the resident was found verbally unresponsive, with an Accucheck (a test to check blood sugar levels) of 90. The resident was sent to the Emergency Room and returned to the facility later that same day on 04/16/04, large amounts of greenish drainage noted and the resident was complaining of pain. He was given Darvocet for the pain but on 04/24/04, the wound site was oozing 42 "yellowish cream pus." The resident continued to have problems with the wound discharge and on 05/07/08, at 6:30 pm, the resident had a temperature of 101.2, which was treated with Tylenol. At 7:00 pm the resident temperature was 100.3. (d) On 05/08/04, the resident sedimentation rate (a blood test used to screen for inflammation) was 140. The normal values are between 0 -15. The resident's physician ordered Levaquin antibiotic with orders for the resident to be seen in his office that Monday (may 10°). The next day, 05/10/04, at 9:00 pm the resident had a temperature of 99.3 and he was treated with Tylenol. On 10:00 pm, the resident had a purulent discharge, an elevated temperature of 98.1. The resident was given Percocet for the pain and on 05/10/04; the resident was transferred to the hospital with a diagnosis of right hip infection. On 05/21/04 the resident had surgery for the removal of the right hip prosthesis due to the infection of the right hip. (e) The facility failed to ensure that the resident was adequately monitored for his medical condition, even though the facility was aware of his medical condition. As a result of the facility's inability to monitor the care and services to this resident, the resident's condition continued to deteriorate and on 05/21/04 the resident had 43 surgery for the removal of the right hip prosthesis due to an infection of the hip. 36. Review of Resident #7 (R7) medical record revealed that he/she was admitted to the facility on 04/05/04 after being hospitalized. The resident has a diagnosis of Congestive Heart Failure (CHF), anemia, arterial cardio- vascular disease (ACVD), Degenerative Joint Disease (DID), Breast Mass, history of Urinary Tract Infection (UTI), Gastro Intestinal bleeding (GI) arthritis, generalized swelling and renal failure. The resident is incontinent of bowel and bladder with poor mobility. The resident care plan dated 06/02/03 and recently updated on 04/16/04 identifies the resident at being at-risk for skin alternations. Even after new pressure areas were identified, there was no further attempt to update the care plan to reflect the resident's condition. R7 developed 3 in-house, stage II ulcer (a partial thickness of skin layers either dermis or epidermis that presents clinically as an abrasion, blister, or shallow ulcer) pressure areas (04/17/04, 05/02/04, 05/12/04 and 05/14/04) and the staff failed to ensure that this resident, who was identified as high risk for skin alteration, was being routinely monitored. (a) A review of the nurse's notes dated 04/17/04 revealed that a stage II pressure sore of the left coccyx, measuring 1 cm wide and 1 cm long. On 05/02/04 a new stage 44 II pressure area measuring 3 cm wide and 2 cm long was discovered on the resident's right buttock. On 05/12/04 there is a new indication of a reddened area (unstaged) on the left big toe. There is a physician's order dated 04/30/04 to treat the area, however, there is no other documentation in the record that can speak to the date of this new area and the staging. On 05/14/04 another new stage II pressure ulcer measuring 0.5 cm x 2cm was found on the back of the resident's right upper thigh. (b) A review of the facility's Skin Policy and Procedure states that "upon detection that a resident has alteration of skin integrity, the nurse will notify the rehabilitation and dietary department via written communication." Dietary was only notified of the 05/02/04 pressure area and a dietary assessment was completed 10 days later on 05/12/04. There is no evidence that the rehabilitation department was ever informed of the resident's condition. The policy also states that a Braden Scale (a tool for predicting pressure sore risk) would be completed and a care plan and Minimum Data Set (MDS) will be reviewed. There is no evidence that this was completed and a further review of the record revealed a blank Braden Scale form. (c) On 05/22/04 at 3:15 pm, the RD was interviewed regarding the lack of dietary interventions for 45 the pressure sores that were identified on 04/17 and 05/14/04 and the reddened, unstaged area on the left big toe. The RD was not aware that the resident had multiple pressure areas since admission. The facility had failed to utilized its’ resources effectively and efficiently to ensure that this resident's skin condition did not deteriorate. 37. Based on the foregoing, Key West Convalescent Center, Inc. violated Title 42, Section 483.75, Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code, and Section 400.147(2), Florida Statutes, and the Agency has imposed a Class I widespread deficiency, which carries, in this case, an assessed fine of $15,000.00. However, in this case, the Agency has doubled the $15,000.00 fine and has imposed a total fine of $30,000.00 pursuant to Section 400.23(8) (a), Florida Statutes (2003). Section 400.23(8) (a) requires the fine to be doubled if the facility has been previously cited for one or more Class II deficiencies during the last annual inspection or any inspection or complaint investigation since the last annual inspection. The facility was cited for a Class II violation on 2/26/04 (AHCA #2004002850). This Administrative Complaint was served and the facility has requested a formal hearing. The facility was also cited for a Class II violation on 5/2/04 (AHCA # 2003002419). 46 COUNT V ADDITIONAL FINE UNDER SECTION 400.19(3), FLORIDA STATUTES 38. The Agency, in addition to any administrative fines imposed, may assess a survey fee. The fine for the 2- year period shall be $6,000.00, one half to be paid at the at the completion of each survey. PRAYER 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 V. B. Assess an administrative fine of $110,000.00 against Key West Convalescent Center, Inc. on Counts I through IV for four Class I violations. Cc. Assess a fine of $6,000.00 survey fee on Count V pursuant to Section 400.19(3), 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 (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 47 for Health Care Administration, and delivered to the Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, attention Agency Clerk, telephone (850) 922-5873. 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. ourdes A. Naranjo Fla. Bar 997315 Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N. W. 52°? Terrace Miami, Florida 33166 305-470-6801 Fla. Bar 997315 Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration 8355 N.W. 53°% Street Miami, Florida 33166 (Inter-office mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Inter-office -Mail) 48 Long Term Care Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 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 Key West Convalescent Center, c/o Administrator, 5860 West Junior College Road, Key West, Florida 33040, and to Patrick Gordon, Registered Agent, 810 turn Street, Suite #17, Jupiter, Florida 33477 on urdes A, Naranjo 49

Docket for Case No: 04-002764