Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: THE PARKS HEALTH CARE ASSOCIATES, LLC, D/B/A PARKS HEALTHCARE AND REHABILITATION CENTER
Judges: DANIEL M. KILBRIDE
Agency: Agency for Health Care Administration
Locations: Orlando, Florida
Filed: Sep. 21, 2004
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Monday, November 29, 2004.
Latest Update: Jan. 13, 2025
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Petitioner, AHCA No.: 2004004026;
AHCA No.: 2004003801
Return Receipt Requested:
7003 1680 0006 9825 8878
THE PARKS HEALTH CARE ASSOCIATES, 7003 1680 0006 9825 8892
Lcc, d/b/a PARKS HEALTHCARE AND
REHABILITATION CENTER, .
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v.
Respondent.
ADMINISTRATIVE COMPLAINT
COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”),
by and through the undersigned counsel, and files this
Administrative Complaint against THE PARKS HEALTH CARE ASSOCIATES,
LLC, d/b/a PARKS HEALTHCARE AND REHABILITATION CENTER,
(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.
2003003801].
2. This is an action to impose a conditional licensure
rating pursuant to Section 400.23(7) (b), Florida Statutes
(2003) [AHCA Case No. 2004004026].
3. The Respondent was cited for the deficiencies set
forth below as a result of an Annual Licensure and
Recertification survey conducted March 29 - April 1, 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 Orange 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 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 9311 S.
Orange Blossom Trail, Orlando, FL 32837. Respondent is
licensed to operate a skilled nursing facility pursuant to
license #SNF1089096. 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 ENSURE THAT EACH RESIDENT RECEIVED
AND THE FACILITY PROVIDED THE NECESSARY CARE AND SERVICES
TO ATTAIN OR MAINTAIN THE HIGHEST PRACTICABLE
PHYSICAL, MENTAL, AND PSYCHOSOCIAL WELL-BEING, IN VIOLATION OF
42 C.F.R. SECTION 483.25 AS INCORPORATED BY RULE 59A-4.1288
FLORIDA ADMINISTRATIVE CODE
CLASS II DEFICIENCY
ISOLATED
8. AHCA xre-alleges and incorporates paragraphs (1)
through (6) as if fully set forth herein.
9. On or about March 29 - April 1, 2004, AHCA conducted
an Annual Licensure and Recertification survey at Respondent ’s
facility.
10. Based on observations, interviews and clinical record
reviews, the facility failed to ensure care and services were
provided to: a) monitor and medicate for complaints/facial
grimaces of pain during wound care through assessment, care
planning and following physician's orders (#12 & 14); b) prevent
digital disimpaction for constipation by following physician's
orders and bowel elimination program (#1); ¢) administration of
a laxative that was not ordered by the physician (#5) and qd)
provide a bone scan report requested by two physician's to rule
out cause of pain and possible needed follow-up (#11) for a
total of 5 of 23 sampled residents.
The findings include:
1. Observation of resident #14 on 3/29/04 at approximately 9:35 a.m. with a
nurse and certified nursing assistant (CNA) present, identified the resident in bed
being prepared for wound care treatment. The resident was observed to have
dressings to both lower heels and the right great toe.
The treatment began by the CNA lifting the resident's left leg and holding it up so
the nurse could remove the dressing to the left heel. Observation of the left heel
identified a necrotic area measuring 5.7 centimeters (cm.) by 4.9 cm. The
resident moaned in pain and tried to pull his/her left leg from the CNA's grip. The
CNA held the left leg tighter. The nurse then proceeded to remove the old
dressing from the right heel and right great toe. Observation of the right heel
identified a gangrenous area measuring 53. cm. by 8.3.cm. The heel was
observed to be demarcating from the right foot. The area above the demarcation
was observed to be red with some areas with the beginning of necrosis. The
resident yelled, moaned and grimaced with pain. The CNA was holding the
resident's right leg up and again, the resident was trying to pull the leg from the
CNA's grip while crying out, "it hurts ". Interview was conducted at this time with
the nurse and CNA. The CNA stated, "the resident is ina lot of pain". The nurse
stated, “the areas are gangrene and painful." Questioning the resident numerous
times during the thirty five minute observation of the treatment, the resident
nodded "yes" and stated that he/she was in pain.
Interview with the medication nurse was conducted on 3/29/04 at approximately
10:10 a.m. The medication nurse stated, "yes, the resident is in a lot of pain. The
resident was medicated with Tylenol extra strength one tablet at 6:00 a.m."
Clinical record review for resident #14 was conducted on 3/29/04 at
approximately 11:00 a.m. The resident was admitted to the facility on 1/16/04.
Diagnoses included osteoporosis, congestive heart failure, hypertension, anemia,
deep vein thrombosis and severe atherosclerotic occlusive disease to lower
extremities and dementia.
Review of resident #14's minimum data set (MDS), dated 1/26/04 and identified
as an initial assessment, coded the resident's cognitive skills as moderately
impaired, decisions poor, cues supervision required. Poor recall with short and
long term memory. The resident was understood in expressing information and
usually understands information.
Review of nurses’ notes revealed the following:
2/09/04 @ 6 a.m. - "Refuse knee adapter screaming of pain when applied.
Regular schedule Tylenol."
2/16/04 @ 6 a.m. - "Tylenol given for pain."
2/16/04 @ 9:30 a.m. - "Resident alert, screaming at moving. Grimacing face of
pain right leg Darvocet one tab given, was effective.”
2/18/04 @ 11 a.m. - "Grimacing face of pain, screaming, yelling stated pain on
right leg. Pain medication given."
2/19/04 @ 11 a.m. - "Complain of pain on both legs. Pain medication given.”
2/20/04 @ 10 a.m.- "Alert, in pain on right heel and feet. Medication was given
at 7:30 a.m.
2/24/04 @ 1 p.m. - "Alert, responsive in pain. Medication given and was
effective."
2/25/04 @ 11 a.m. - "Remains with pain on right big toe, dark skin color, painful
at touch and cleaning. Medication was given and was effective."
2/26/04 @ 11 a.m. - "Resident screaming, yelling, stated pain on right feet and
Jeg. Medication given and was effective.”
2/27/04 - “Alert, communicative, complain of pain on right heel. Medication
given.”
3/08/04 @ 6 a.m. "Complain of pain both legs. Tylenol given. Some relief."
3/12/04 - "Complain of pain. Pain medicine given and was effective."
3/29/04 @ 2 p.m. - "Resident alert, responsive with pain on both legs and heels.
Medication for pain given.”
Review of the physician's orders for resident #14 revealed a physician's order for
Darvocet N-100, one tab every four (4) hours as needed (PRN) for pain. Review
of the physician ordered services (POS) revealed the physician's order was
changed on 2/20/04 from PRN to Darvocet N-100 every four (4) hours for pain.
Interview with the unit manager was conducted on 3/3 1/04 at 2:45 p.ra. regarding
clarification of the Darvocet order. The nurse stated, "I called the physician and
he/she feels the resident needs the Darvocet around the clock.”
Review of the medication administration record (MAR) for resident #14 on
3/29/04 at approximately 3:00 p.m. revealed the resident was not receiving the
Darvocet as ordered every four hours.
Review of the physician's progress notes on 3/30/04 at approximately 9:30 a.m.
revealed the following:
2/22/04 - "Worsening /progression of gangrene, cellulitis to right foot/ lower leg.
Pain management. Hospice recommended. Strongly recommend
hospice/amputation.”
3/08/04 - "Patient's gangrene progressing.”
3/22/04 - "Gangrene dry. Severe Peripheral Vascular Disease."
Review of a Rehabilitation Discharge Summary by Physical Therapy dated
2/11/04 revealed the following:
“Patient has very poor tolerance to standing with complaint severe pain in right
lower extremity secondary to thrombus. Patient to continue with restorative nurse
program.”
Interviews conducted during the survey on various days/times revealed the
following:
a) Unit Manager 3/30/04 at 11:10 am. - "I admitted the resident. I washed the
heels and saw the black heels and toe. The resident was in a lot of pain. I knew
the resident had severe circulation problems."
b) Certified Nursing Assistant (CNA) 3/31/04 at 12:30 p.m. dining room- "I try to
make sure resident eats. The resident is in a lot of pain. The resident goes back to
bed right after lunch.”
c) Unit Manager 3/31/04 at 2:15 p.m. - "The only pain management program in
place is on the medication administration (MAR) record or treatment
administration record (TAR).”
Review of the MAR and TAR with the nurse present on the above date and time
identified no pain management program in place.
d) Administrative staff 3/31/04 at 4:15 p.m. - "We have pain management forms
on the Mar’s that the nurses should be filling out, but they were not transferred to
the new MARs."
e) CNA 4/01/04 at 9:45 a.m. - "I can't believe it, the resident wasn't medicated for
pain all the time. The resident is always in pain, at least on the day shift."
Review of the facility's policies and procedures on Pain Management & Comfort
Promotion dated 8/02 revealed the following:
"1, Each resident/patient is evaluated upon admission, with change in clinical
condition and quarterly for new indicators of discomfort and/or pain.
a) Self-Report for residents/patients who have the ability to self-report discomfort
and/or pain.
b) Clinical indicators and/or behavior characteristics for a resident/patient unable
to provide a self-report.
2. Complete the Discomfort & Pain Data Collection (FSE 3-6-1).
3. Evaluate reasons a resident/patient is experiencing discomfort and/or pain.
a) Medical condition/diagnosis.
4. Develop the Plan of Care: Pain Management (FSE 3-6-3) with input from the
interdisciplinary team."
Review of the clinical record, MAR and TAR identified no plan of care for
resident #14.
2. Clinical record review for resident #1 on 3/30/04 at approximately 8:45 a.m.
revealed an admission date of 9/02/03. Diagnoses included hypertension,
dementia, hearing loss and diabetes.
Review of the resident's most recent MDS revealed a significant change was
completed on 2/05/04 due to a decline in cognitive status. The resident was coded
as "2", moderately impaired cognitive skills with a short and long term memory
deficit.
Review of the nurse's notes for resident #1 on 3/30/04 at approximately 9:00 a.m.
identified the following:
2/28/04 at 2330 - "Resting in bed confused- fecal impaction hard stool removed
digitally. Large in amount."
3/01/04 at 12:00 p.m. - "Notified about resident's constipation condition. Ordered
Colace, fleet enema whenever necessary (PRN), and Milk of Magnesia (MOM)
PRN. Has a extra large bowel movement today.”
3/04/04 at 6 a.m. - "Resident has fecal impaction. Unable to remove digitally.
MD notified ordered for fleet enema STAT-and is given. Has extra large
formed."
3/10/04 at 10 a.m. - "Resident with severe constipation. MOM 30 cc (cubic
centimeters) by mouth given. Able to remove fecal impaction digitally. Do extra
large bowel movement. Evaluate by dietician. Dietician recommend Marinol for
increase appetite.”
Review of the facility's policy and procedures on constipation on 3/31/04 at
approximately 2:45 p.m. revealed the following:
"A resident/patient with bowel elimination will have the appropriate interventions
to prevent and/or resolve constipation.
a) CNAs - At the end of each shift the CNA will record in the (Activities of Daily
Living) ADL record if the resident has had a bowel movement (BM). CNAs will
report to the nurse's size and number of BM'’s at the end of each shift
b) Licensed nurses - On the MAR there is a place for you to document results of
bowel movements. If there are no bowel movements for three (3) days in a row
you must go to the PRN MAR and follow the doctors order for the resident."
Review of the MARs and ADL flow sheets on 3/31/04 at approximately 2:10 p.m.
revealed for the month of February, only two (2) days of documentation of the
resident's bowel movement monitoring matched when compared. There were
discrepancies with the remaining 27 days related to size and if the had a bowel
movement. Review of the March MAR and ADL flow sheet found only two (2)
days where documentation matched when the resident had a bowel movement and
size of the movement. There were discrepancies with the remaining 29 days.
Also, there was no documentation of the consistency of the bowel movement.
Review of the MAR for the month of February on 4/01/04 at approximately 9:00
am. revealed the resident did not receive milk of magnesia (MOM) per order.
Review of the MAR for the month of March 2004 revealed the resident received
MOM on March 8, 9, 10 and 11, 2004. Review of the MAR and ADL flow sheet
revealed the resident had BMs on the above dates.
Review of dietary notes on 3/31/04 at approximately 4:10 p.m. revealed a note by
the dietician dated 3/10/04 and which read: "History of constipation/fecal
impaction. Will add prune juice ever day at breakfast."
Observation of the resident's breakfast tray for three (3) days of the survey
identified no glass/cup of prune juice present on the breakfast tray. Review of the
resident's tray card did not have prune juice listed.
Interview was conducted with the unit manager on 4/01/04 at approximately
10:00 am. The unit manager stated, "the resident was ordered prune juice and
there is a physician's order for it. I'll call dietary to see what they have written on
the tray ticket." Further interview was conducted with the unit manager on
4/01/04 at approximately 10:35 a.m. The unit manager stated, "the order for the
prune juice failed to be given to dietary, but they have it now."
3. Record review revealed no report of the results of a bone scan done 1/06/04 of
resident #23, in spite of doctor's orders written on 2/02/04 and again on 2/24/04
requesting that the bone scan report be obtained and placed on the chart for
review. When the results were obtained on 3/30/04, the report contained the
phrase "clinical correlation is needed" which had not been done due to the
absence of the bone scan report from the chart. These findings were confirmed by
interview with the West wing unit manager at approximately 2:50 p.m. on
3/30/04.
4. Observation of dressing changes on stage IV pressure ulcers of both heels of
resident
#12 revealed that the resident grimaced, groaned and attempted to pull away from
the wound care nurse doing the dressings. When questioned, the resident denied
pain but continued the aforementioned "body language" gestures through out the
2 dressing changes which lasted from approximately 11:25 a.m. through 11:45
a.m. on 3/30/04.
Interview with the wound care nurse during and immediately after the dressing
changes confirmed the nurse felt the resident was in pain. Record review revealed
that no pain medication was offered to the resident until approximately 1:00 p.m.
on 3/30/04, at which time the resident accepted the Darvocet-N 100 which had
been ordered on 2/05/04 to be given as needed for pain. These findings were
confirmed by interview at that time with the medication nurse and the unit
manager.
5. Review of the clinical record on 3/29/04 for resident #5 revealed a March 2004
physician's order for herbal laxative (start date 9/20/02), 3 tabs orally (po) every
other day (qod) at night (hs). Another order was for senokot 1 tab po ghs pm
(sennosides).
Interview with nurse at approximately 10:50 a.m. on 3/30/04 revealed that
senokot was administered as the herbal laxative. Interview with the consultant
pharmacist at 10:55 a.m. revealed that the pharmacy did not have a product that
was an herbal laxative. Interview with the unit manager at approximately 11:00
a.m. confirmed that the order should have been clarified.
11. Respondent was provided a mandated correction date of
April 22, 2004.
12. The above actions or inactions are a violation of 42
CFR 483.25, as incorporated by Rule 59A-4.1288, Florida
Administrative Code, which requires the facility to ensure that
each resident must receive and the facility must provide the
necessary 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.
13. Pursuant to Section 400.23(8) (b), Florida Statutes
(2003), the foregoing is an “isolated” class I! 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, and 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 inspection
or complaint investigation since the last annual inspection. A
fine shall be levied notwithstanding the correction of the
deficiency.
14. A civil penalty is authorized and warranted in the
amount of §2,500, as this violation constitutes an “isolated”
Class II deficiency.
15. 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 on
Count I of the complaint;
b. Impose a $2,500 civil penalty against Respondent
pursuant to Section 400.23(8) (b), Florida Statutes
(2003);
c. Assess costs related to the investigation and
prosecution of this case, pursuant to Section
400.121(10), Florida Statutes (2003), if
appropriate.
10
d. Uphold the conditional licensure status pursuant to
Section 400.23(7) (b), Florida Statutes (2003); and,
e. Grant any other general and equitable relief as
deemed appropriate.
NOTICE
The Respondent is hereby notified that it has a right to
request an administrative hearing pursuant to Section 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:
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.
urdes A. Naranjo, Esq.
Assistant General Counsel
Agency for Health Care
Administration
8350 N.W. 52 Terrace - #103
Miami, Florida 33166
305-470-6801
1
Copies furnished to:
Joel Libby
Field Office Manager
Hurston South Tower
400 West Robinson Street - Suite S309
Orlando, Florida
(U.S. Mail)
Long Term Care Program office
Agency for Health Care Administration
2727 Mahan Drive
Tallahassee, Florida 32308
(Interoffice Mail)
Jean Lombardi
Finance and Accounting
Agency for Health Care Administration
2727 Mahan Drive - Mail Stop #14
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 Eloise Abrahams, Administrator, Parks
Healthcare and Rehabilitation Center, 9311 S. Orange Blossom
Trail, Orlando, Florida 32837; CT Corporation System, 1200 South
7
Pine Island Road, Plantation, Florida 33324 on this /é day
/
fot tee, (yj Vay bes
rdes A. Naranjo, Esq.
of 2004.
12
Docket for Case No: 04-003374
Issue Date |
Proceedings |
Feb. 14, 2005 |
Final Order filed.
|
Nov. 29, 2004 |
Order Closing File. CASE CLOSED.
|
Nov. 23, 2004 |
Motion to Remand without Prejudice filed.
|
Nov. 10, 2004 |
Letter to DOAH from D. Aldrich enclosing a notice of service of answers to interrorgatories (filed via facsimile).
|
Nov. 09, 2004 |
Notice of Deposition (Petitioner`s Representatives) filed via facsimile.
|
Nov. 05, 2004 |
Response to Request for Production of Documents (filed by Respondent via facsimile).
|
Nov. 05, 2004 |
Response to Peitioner`s First Request for Admissions (filed via facsimile).
|
Oct. 06, 2004 |
Order. (ordered that R. Davis Thomas, Jr., is authorized to appear in this administrative proceeding as the qualified representative of Respondent)
|
Sep. 30, 2004 |
Notice of Service of Petitioner`s First Set of Request for Admissions, Interrogatories, and Request for Production of Documents (filed via facsimile).
|
Sep. 30, 2004 |
Affidavit of R. Davis Thomas, Jr. (filed via facsimile).
|
Sep. 30, 2004 |
Motion to Allow R. Davis Thomas, Jr. to Appear as Parks Healthcar`s Qualified Representative (filed via facsimile).
|
Sep. 30, 2004 |
Order of Pre-hearing Instructions.
|
Sep. 30, 2004 |
Notice of Hearing (hearing set for November 30, 2004; 9:00 a.m.; Orlando, FL).
|
Sep. 28, 2004 |
Joint Response to Initial Order (filed via facsimile).
|
Sep. 22, 2004 |
Initial Order.
|
Sep. 21, 2004 |
Conditional License filed.
|
Sep. 21, 2004 |
Standard License filed.
|
Sep. 21, 2004 |
Order of Dismissal without Prejudice Pursuant to Sections 120.54 and 120.569, Florida Statues and Rules 28-106.111 and 28-106.201, Florida Administrative Code to Allow for Amendement and Resubmission of Petition filed.
|
Sep. 21, 2004 |
Amended Request for Formal Administrative Hearing filed.
|
Sep. 21, 2004 |
Request for Formal Administrative Hearing filed.
|
Sep. 21, 2004 |
Administrative Complaint filed.
|
Sep. 21, 2004 |
Notice (of Agency referral) filed.
|