STATE OF FLORIDA : f ~ he AGENCY FOR HEALTH CARE ADMINISTRATIQW rp XP 9, < De AGENCY FOR HEALTH CARE los Mtg, fo ADMINISTRATION, AOK, iy < aeetiya 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, . O-227Y 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