STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION 1 AGENCY FOR HEALTH CARE ; ADMINISTRATION, Petitioner, vs. Case Nos. 2004003614 2004001844 DESOTO HEALTH & REHAB, LLC, _ DY. 3lwd Respondent. Le =) ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, .and files this Administrative Complaint against DESOTO HEALTH & REEAB, LLC, (hereinafter “Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine against Respondent, in the amount of two thousand five'hundred dollars ($2,500) pursuant to Sections 400.102 (1) (a) and (d), 400.19 and 400.23(8) (b), Florida Statutes (2003) [AHCA Case No. 2004001844). Page 1 of 13 AHCA cases 2004003614 and 2004001844 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes (2003) [AHCA Case No. 2004003614). 3. The Respondent was cited for the deficiencies set forth below as a result of an Annual Licensure and Recertification survey conducted on or about February 4, 2004. JURISDICTION AND VENUE 3. The Agency has jurisdiction over the Respondent pursuant to Chapter 400, Part II, Florida Statutes (2003). 4, Venue lies in Desoto County, Division of Administrative Hearings, pursuant to Section 120.57, Florida 4 Statutes (2003), and Chapter 28-106, Florida Adminigtrative Code (2003). PARTIES 5. AHCA, Agency for Health Care Administration, is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable state statutes and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida statutes (2003), and Chapter 59A-4, Fla. Admin. Code (2003), respectively. 6. Respondent is a nursing facility located at 1002 North Brevard Avenue, Arcadia, FL 34266. Respondent is Licensed to operate a skilled nursing facility pursuant to license Page 2 of 13 ' AHCA cases 2004003634 and 2004001844 #SNF11270961. At all relevant times, Respondent was a licensed fatility required to comply with all applicable regulations, statutes and rules under the licensing authority of AHCA. counr_ RESPONDENT FAILED TO ENSURE THAT RESIDENTS RECEIVED THE NECESSARY CARE AND SERVICES TO EITHER PREVENT THE DEVELOPMENT OF PRESSURE SORES OR TO PROMOTE HEALING OF PRESSURE SORES, OR TO PREVENT INFECTION OF PRESSURE SORES. FLA. ADMIN. CODE R.59A-4.1288(2003), INCORPORATING BY REFERENCE 42 CFR 483.25(C) (2003) CLASS II DEFICIENCY ISOLATED 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. ' ' 8. On or about February 4, 2004, AHCA conducted an Annual Licensure and Recertification survey at Respondent’s facility. 9. Based on observation, review of the clinical record and wound summary and interview with nursing staff, the facility failed to implement timely preventative measures to prevent and/or minimize the risk for skin breakdown and following the development of in-house acquired pressure sores; the facility failed to obtain physician orders to treat the pressure sore on the left buttock and did not obtain orders to treat the pressure sore on the right buttock until 7 days after the pressure sores were identified. The facility also failed to cover the pressure sore with a dressing, failed to turn and reposition the resident Page 3 of 13 ’ AHCA cases 2004003614 and 2004001844 ‘off the wound area every 2 hours in the bed and chair per the care plan, failed to place the resident on a pressure relieving device in the geri chair and failed to apply heel protectors as ordered for 1 (Resident #3) of 7 active sampled residents reviewed for pressure sores from a total sample of 15. The findings include: 1. Resident #3 is a long-term resident of the facility who is in a vegetative state receivine total nutrition via a tube feeding and custodial care at the facility. On 10/22/03, the resident was readmitted to the facility following replacement of her feeding tube with diagnoses including stroke, dementia, Type 2 diabetes, contractures, vegetative state and a pressure sore on her left buttock.’ The development of the pressure sore placed the resident at high risk for alteration in skin integrity requiring treatmert to heal the pressure sore and implementation of preventative measures to decrease the potential for the pressure sore to re-open or development of' new areas. Observation of the resident on 2/2/04 at approximately 10:20 A.M., revealed 2 Certified Nurses Aide (CNAs) were putting the resident back to bed after being weighed. The resident was placed on her back on a threadbare sheet with no pressure relieving pad on her bed. The nurse surveyor was requested to observe the resident's skin for pressure areas. Observation of the resident at approximately 10:30 A.M., by the nurse surveyor, revealed no dressings on the resident's buttocks. The resident had one dime-size open area on the left buttock that was not covered by a dressing. The right buttock had old scar tissue from previous open areas. Observation of the resident on 2/2/04 at approximately 11:15 A.M., revealed the resident remained in bed positioned on her back with the head of the bed elevated secondary to being on a continuous tube feeding. A wedge cushion was observed in the room, Page 4 of 13 AHCA cases 2004003614 and 2004001844 but was not used to position the resident off the wound area. At approximately 3:00 P.M. on 2/2/04, the nurse surveyor requested to observe the resident's wounds with the nurse and questioned her regarding the lack of a dressing on the pressure area. The day shift nurse confirmed that the resident had no dressing on the pressure sore. She stated, "I had to go ahead and put ‘that dressing on. She needed it." Observation of the resident on 2/2/04 at 3:35 P.M., by the nurse surveyor and the evening shift nurse, revealed a 1 X 2 bandage on the coccyx area. A dime- size open area was observed on the resident's left buttock that was open and exposed to the air with no dressing covering the pressure sore. The bandege was removed from the coccyx area by the staff nurse for observation by the nurse surveyor. No open areas were observed on the skin where the bandage had beer: placed. The area under the dressing was only scar tissue from previous pressure areas. Interview with the staff nurse on 2/2/04 at 3:35 P.M., regarding the location of the wound revealed, "This is the same wound I've been putting Polymen on for at least the past week." The nurse confirmed that there were no other open areas except for the wound on the left buttock. Observation of the resident on 2/3/04 at approximately 10:10 A.M. revealed the resident seated in a geri chair in the East Wing Day Room. The resident was positioned on her back with a rolled up blanket. placed on her right side, wedging the resident betweer the blanket and the left side of the geri chair. There was no pressure relieving cushion in the chair. The footrest had not been elevated to raise the resident's legs and feet and the resident's feet were dangling off the end of the chair. The resident had white socks on and no heel protectors. Observation of the resident on 2/3/04 at 1:40 P.M. revealed that the resident was back in bed positioned on her back on the pressure sore area in a mounded position with her chin against her chest and slumped down into the bed due to the elevated head of bed at a 60 degree angle. There was no pressure relieving Page 5 of 13 AHCA cases 2004003614 and 2004001844 device on the bed. The resident was positioned so there was increased pressure on her buttocks. The resident did not have heel protectors on and her heels were resting on the mattress. The geri chair that the resident was sitting in earlier was in the room and it did not have a pressure relieving cushion on it. The wedge cushion was across the room and not in use to position the resident off the pressure sore area. Observation of Resident #3 on 2/4/04 at 11:15 A.M., revealed the resident sitting up in a geri chair positioned on her back. Further observation of the , resident at 11:25 A.M., 1:45 P.M., 2:00 P.M. and 2:15 P.M., revealed the resident remained seated in the chair in the same position on her back with no repositioning for a 3 hour period. At 2:30 P.M., the resident was observed back in bed placed on her back. Review of the 1/19/04 Wound Summary, provided by the Assistant Director of Nursing (ADON), revealed that the resident had two Stage II in-house acquired pressure sores which developed on 12/28/03. One was 0.5 centimeters, red, open, without drainage, Stage II on the right buttock and the other was a 0.5 centimeter, red, open, without drainage, Stage II on the left buttock. The documentation indicated that the pressure sores were being treated with Polymen dressings. . ; Review of the nurse's notes from 12/28/03 through 2/2/04, revealed conflicting data regarding the total number, location and status of the resident's pressure sores. The 11 P.M. to 7 A.M. nurse first noted the observation of a pressure sore on the left side between the buttock area on 12/28/03. She documented that she would report the open area to the day shift nurse for treatment. There was no further documentation in the nurse's notes that indicated that the newly observed pressure area was reported to the day shift nurses to obtain treatment orders. Review of the physician telephone orders from 12/29/03 through 12/31/03, revealed no order for treatment for the pressure sore on the left buttock. Further review of the physician's telephone orders revealed an order Page 6 of 13 ‘ AHCA cases 2004003614 and 2004001844 was obtained, 7 days later, on 1/4/04 at 10:00 P.M. for Polymen dressing to the right buttock, change every day on 3 P.M. to 11 P.M. shift until healed. The order noted the pressure sore was an open area 0.5 centimeters. There were no orders for treatment of the pressure sore on the left buttock until surveyor intervention on 2/3/04, which was 37 day after the identification of the pressure sore. Review of the January 2004 and February 2004 Treatment Records confirmed documentation of the Polymen dressing being applied to a pressure sore on the right buttock and no documented treatment to the pressure sore on the left buttock. ' Review of care plan #4 for alteration in skin integrity, updated 12/28/03, revealed inaccurate documentation of the resident's pressure sore status. Care plan approaches included: turn and reposition at least every 2 hours in and out of bed, pressure relieving mattress, heel protectors and pressure relieving cushion when up in geri chair. The resident also had an order from the' physician on 2/2/03 for heel protectors to prevent skin breakdown. Observations during the survey from 2/2/04 through 2/4/04 confirmed that these preventative skin measures were not being utilized on a consistent basis. Further review of the Wound Summary, completed by the ADON on 1/26/04, revealed that the pressure sore on the right buttock, which had been receiving treatment, had healed. The ADON documented that the pressure sore on the left buttock was 0.5 centimeter, red and open, without drainage. It was inaccurately ‘ documented that this wound was being treated with Polymen. Review of the physician's orders, telephone orders and treatment records from 1/26/04 through 2/2/04 indicated no documented treatment for this pressure sore, as verified by two observations by the nurse surveyor on 2/2/04. During interview with the Director of Nursing (DON), the Administrator, the ADON and other facility staff on 2/3/04 at 2:10 P.M., the ADON confirmed that the Page 7 of 13 AHCA cases 2004003614 and 2004001844 nursing staff were supposed to record the pressure sore assessment on the new nursing progress note form. She stated that this form was started 3 weeks ago and there was a miscommunication with the staff nurses regarding documentation of pressure sores. She further stated that the nurses were not addressing areas that were not a change from "baseline"; but they misunderstood that this did not apply to pressure sores. The DON stated that she had implemented this form so that the nurses could keep the form in their pockets and document the wound assessment at bedside. She confirmed that she did not know why the nurse documented’ that the resident had no open areas on 2/2/04. The DON further stated that she would look at the resident's wound herself and inform the surveyors of the resident's current wound status. During interview with the Director of Nurses on 2/4/04 at 8:45 A.M., she confirmed that the resident has an open area on her left buttock. Regarding the nurse's documentation of 2/2/04 she stated that the nurse did not do a thorough evaluation to assess the resident's wounds. She further stated that the resident had returned from the hospital in 10/03 with the left buttock wound, it had healed and reopened on 12/28/03. She stated that she could not determine why the nurse put the wound dressing on incorrectly and did not cover the pressure sore on 2/2/03. . The DON further stated that the resident was obese, contracted and difficult to position and had poor wound healing secondary to diabetes. She also stated that after meeting with, the surveyors and observing the wound herself on 2/3/04 they had put the resident on an air mattress, added a gel cushion to the geri chair and instructed the staff to use the wedge when the resident was in bed. She obtained an order for 2 staff to turn the resident at all times. The DON confirmed that these preventative measures were not implemented soon enough to prevent the pressure sore development. She stated, "What we were doing to prevent pressure sores was working up until 12/28/03. At 9:10 A.M., the DON again re-confirmed that the pressure sores could have been prevented with proper treatment by the nursing staff. Following surveyor intervention, review of the clinical record revealed physician's telephone orders Page 8 of 13 AHCA cases 2004003614 and 2004001844 on 2/3/04 at 1700 for pressure relieving mattress (air) and clarification order for Polymen dressing to ; ‘ left buttock, change evéry day on 7 A.M. to 3 P.M. shift till healed after the. ADON was informed about the lack of an order for treatment for the pressure sore on the left buttock by the nurse surveyor. On 2/3/04, after the meeting with the surveyors, the DON obtained the following orders from the physician: turn resident and give hygiene/incontinent care with 2 CNAs, turn resident off back using wedge cushion when turning to the side and gel cushion to geri chair when out of bed. 10. Respondent was provided a mandated correction date of March 5, 2004. 11. The above actions or inactions are a violation Rule 59A-4.1288, Florida Administrative Code (2003), inccrporating by reference 42 Code of Federal Regulations 483.25(c) (2003), which requires the facility to provide each resident the necessary i] care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. As it relates to pressure sores, based on the comprehensive assessment of a resident, the facility must ensure that: (1) a resident who enters the facility without pressure sores, does not. develop pressure sores, unless the individual's clinical condition demonstrates that they were unavoidable and (2) a resident having pressure sores, receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Page 9 of 13 AHCA cases 2004003614 and 2004001844 D 12. Pursuant to Section 400.23(8) (b), Florida Statutes (2003), the foregoing is an “isolated” class II deficiency and as such, has compromised the resident’s ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, anc provision ' of services. A’ class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 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 4 inspection or complaint investigation since the last annual inspection. A fine shall be levied notwithstanding the correction of the deficiency. 13. A civil penalty is authorized and warranted in the amount of $2,500, as this violation constitutes an isolated” Class II deficiency. 14. Pursuant to Section 400.23(7)(b), Florida Statutes (2003), the Agency is authorized to assign a conditional licensure status to Respondent’s facility. Page 10 of 13 AHCA cases 2004003614 and 2004001844 CLAIM FOR RELIEF 1 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 on Count I of the complaint; b. Impose a $2,500 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. Uphold the conditional licensure status pursugnt to Section 400.23(7) (b) (2003); and e. Grant any other general and equitable relief as deemed appropriate. REMAINDER OF THIS PAGE INTENTIONALLY BLANK GO TO NEXT PAGE Page 11 of 13 AHCA cases 2004003614 and 2004001844 NOTICE The Respondent is hereby notified that it has a right to request an administrative hearing pursuant to Secticn 120.569, 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: 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. Abba) rn. Kodr Wayne D. Knight, Esquir AHCA, Senior Attorney Fla. Bar. No. 0136440 Counsel for Petitioner 525-Mirror Lake Dr. N., #330L St. Petersburg, FL 33731 (727) 552-1525 (office) (727) 552-1440 (fax) Page 12 of 13 AHCA cases 2004003614 and 2004001844 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 No. 7003 1010 0002 4667 0425, to Philip Castleberg, Registered Agent for DeSoto Health & Rehab, LLC, 10C2 North Brevard Avenue, Arcadia, FL 34266, dated on July aa 2004. Quits 4. God edad pow Wayne D. Knight, Esquir Copies furnished to: Philip Castleberg Wayne D. Knight AHCA - Senior Registered Agent for Attorney DeSoto Health & Rehab LLC 525 Mirror Lake Drive, Suite 330L 1002 North Brevard Avenue Arcadia, FL 34266 (U.S. Certified Mail) _ St. Petersburg, FL 33701 ' Philip Sommars Administrator DeSoto Health & Rehab LLC 1002 North Brevard Avenue Arcadia, FL 34266 (U.S. Mail) Page 13 of 13

Docket for Case No: 04-003163