STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2003006065 2003005694 SOUTHWEST FLORIDA RETIREMENT CENTER, INC., St. : d/b/a VILLAGE ON THE ISLE, () (| SHY Respondent. 7 ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against SOUTHWEST FLORIDA RETIREMENT CENTER, INC., d/b/a VILLAGE ON THE ISLE, hereinafter referred to as “Respondent,” pursuant to Sections 120.569, and 120.57, Florida Statutes (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of $12,500.00 against the Respondent, pursuant to Sections 400.23(8)(b), Florida Statutes (2003) [AHCA Case No. 2003005694]. 2. This is an action to assign a conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes [AHCA Case No. 2003006065}. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2003) and Rule 29-106, Florida Administrative Code (2003). 4. Venue shall be determined pursuant to Rule 28-106.207, Florida Administrative Code (2003). PARTIES 5. AHCA is the regulatory agency with regard to nursing home licensure pursuant to Chapter 400, Part II, Florida Statutes (2003), and Chapter 59A-4, Florida Administrative Code (2003). 6. Village on the Isle is a 60-bed skilled nursing facility located at 910 South Tamiami Trail, Venice, Florida 34285 and is licensed under Chapter 400, Part Il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code (2003) 7. Village on the Isle currently is licensed by AHCA as a skilled nursing facility having regained standard licensure on August 28, 2003, had been issued conditional license number SNF1509096, certificate number 10520, with an effective date of July 24, 2003, and an expiration date of July 31, 2003. Following the expiration date of the facility’s license, the conditional license was re-issued with license number SNF1509096, certificate number 1.0523, an effective date of August 1, 2003, and a license expiration date of July 31, 2004. This assigned conditional license is enclosed herewith and a copy attached hereto as Composite Exhibit “A”. Exhibit “A” is incorporated by reference as if it were fully stated herein.’ ee | The Standard license subsequent to Composite Exhibit A is Standard license number SNF1509096, certificate number 10524, with an effective date of 8/28/04, and a license expiration date of 7/31/04. This assigned standard license is attached as Exhibit B. A 8. Village on the Isle is and was at all times material hereto a licensed skilled nursing facility required to comply with Chapter 400, Part 11, Florida Statutes and Chapter 59A-4, Florida Administrative Code (2003). COUNTI VILLAGE ON THE ISLE FAILED TO FOLLOW RESIDENT RESTRAINT STANDARDS Title 42 §483.13(a), Code of Federal Regulation (2003) Rule 59A-4.1288, F lorida Administrative Code (2003) 8. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through seven (7) as if fully set forth herein. 9. Village on the Isle participates in Title XVI or XIX requiring compliance with the certification rules and regulations found in Title 42, Code of Federal Regulation §483.13(a); and as incorporated by Rule 59A-4.1288, Florida Administrative Code. A. Summary of Charges 10. During the annual survey conducted from July 21, 2003 through July 24, 2003 and based on observation, review of clinical records, administrative, nursing, and therapist staff interviews, the facility: a. Failed to allow residents to be free from physical restraints that were used for mere staff convenience, indiscriminately applied restraints without adequate and appropriate assessment, reassessment, and care planning for all devices used as restraints; care b. Failed to disconnect and release restraints per facility protocol and as planned which resulted in actual harm and substandard quality care as evidenced by decline and physical, mental, and psychosocial well-being of residents. il. pertinent here to Respondent and to operation of its facility as a long te! regulations are applied in Florida pursuan The regulatory provisions of the Code of Federal Regulations that are specifically rm care facility, which t to Rule 59A-4.1288, Florida Administrative Code, include, but are not limited to, the following: [42 CFR] Sec. 483.13 Resident behavior and facility practices. (a) Restra imposed for purposes 0 symptoms. ints. The resident has the right to be free from any physical or chemical restraints f discipline or convenience, and not required to treat the resident's medical B. Summary of Findings 12. The findings include the following: A. Resident #4: 1. Review of the Quarterly Addendum Restraint/Side Rail Update dated 10/30/02, 1/16/03 and 4/03 indicated that the resident was independent with mobility, ambulation, and transfer with a rolling walker and a Wanderguard. Review of the clinical record revealed that the resident was admitted to the hospital on 5/28/03 after an un-witnessed fall the previous evening. Per the hospital History and Physical Exam, dated 5/29/03, x-ray demonstrated a right hip fracture and a fractured right arm. The resident returned to the facility after surgery on 6/6/03 with a decline in ambulation and transfer. Review of the Quarterly Addendum Restraint/Side Rail Updated dated 6/6/03 indicated that following the return from the hospital it was determined that the resident needed side rails X 2, a lap buddy in the wheelchair, and a bed and a wheelchair alarm to prevent unsupervised ambulation and bed mobility. Review of the physician's telephone orders dated 6/9/03 revealed an order for the lap buddy when up in the wheelchair to maintain the order for weight bearing as tolerated with supervision. Review of the nurse's progress notes revealed the following: 10. Il. 12. 13. 14. a. 6/25/03 at 8:00 p.m. (late entry), revealed that at 3:00 p.m., the resident was found on the floor near her bed. No injuries were noted. b. 6/26/03 at 10:00 A.M., indicated that the resident was placed in bed with long pillows beside her for safety. 6/26/03, the Quarterly Addendum Restraint/Side Rail Update indicated, “Attempts to get out of bed - bed alarm." The recommendation was a low bed to prevent injury. 6/27/03, a communication form was sent to the Physical Therapist regarding the resident's fall on 6/25/03. The therapist recommended, "use a low bed with high hand rails on both sides. Proper bed positioning with adequate supports should be continued." 6/28/03, nurses progress notes at 3:30 p.m., indicated that the resident was lying on the floor in her room beside the bed and was bleeding from a laceration on top of her head. The resident was sent to the hospital emergency room for staples to her head. 6/29/03, nurses progress notes revealed the following: a. 2:00 p.m. the resident's daughter visited the facility to talk to the Director of Nursing (DON) about getting a restraint. b. 4:30 p.m. a staff member had been put 1:1 with the resident. 6/30/03, a physician's telephone order was obtained to: a. Discontinue the lap buddy due to the resident removing it and attempting to stand-alone. b. A lap belt when up in a chair. c. Aroll belt when in bed due to not asking for assistance or using the call system. d. Ambulation with supervision only. 7/1/03, nurse's progress notes at 2:15 p.m., indicated: a. The resident was monitored frequently while in bed. b. There was no indication that the 1:1 staffing continued after the initiation of the rol] belt. Review of the July 2003 Quarterly Addendum Restraint/Side Rail Update indicated: a. “6/30/03 Roll belt in bed and lap belt in W/C (wheelchair). D/C (discontinue) lap buddy removes. SR (side rails) up X 2. Bed and W/C alarm. Low bed. Body pillows - bed along wall. Floor matt L (left) side.” 15. 16. 17. 18. 19. 20. b. The goal was to prevent independent ambulation to decrease falls and injury. c. The next review date was October 2003. 6/30/03, a Restraint Utilization Assessment was completed for the roll belt and the lap belt. There was no assessment for the low bed, the body pillows or the bed against the wall. 7/2/03, Nurse’s Progress Notes at 12:30 p.m., revealed: The resident needed extensive assistance with Activities of Daily Living. b. The nurse noted that the resident was continuously yelling out, "Hey, come here.” when up in the wheelchair with the lap belt a. on. c. It was noted that Ativan was given at noon as ordered. 7/2/03, Nurse's Progress Notes revealed the following: a. 8:00 p.m. continuous yelling out while up in the wheeichair with the lap belt on. b. 8:30 p.m. the nurse received an order for Haldol for "increased agitation.” c. The resident was given Restoril at 12:30 a.m. (midnight) on 713/03. 7/14/03, Nurse's notes at 6:30 a.m., indicated the following: a. Calling out b. Attempting to get out of bed and throwing body pillow on floor. c. The roll belt was rearranged. d. There was no documentation that the resident was toileted or offered fluids. e. At 8:00 a.m., the nurse gave the resident Ativan. Nurse's notes dated 7/9/03 and 7/14/03 at 4:30 a.m., indicated that: The resident was restless when in bed with the roll belt on and throwing the pillows on the floor. b. The nurses gave the resident Restoril on these dates. a. Review of the resident's Care Plan #2, updated 7/10/03 revealed: It was not updated regarding the discontinuation of the lap buddy. The approaches included e 2. make sure call system is available, observe frequently for need of assistance, 6. answer call bell promptly, 8. wheelchair alarm (6/23/03) and bed alarm, 9. side rails up in bed, 10. long pillows (6/25/03), 21. 22. e 1]. low bed (6/26/03), 12. roll belt in bed - release every 2 hours and position (6/30/03), e 13. lap belt when up in geri chair or wheelchair - release every 2 hours, mealtimes and activities (6/30/03) reassess need and effect every 3 months and as needed, and e 14. Move bed against wall. Right side. Mat on floor left side (7/10/03). On 7/14/03, an evaluation was done for the rol] belt and lap belt. a. The resident's behavior/response to restraint usage was documented as "no adverse reaction.” However, the form also documented that the resident will try to get up from chair/bed, increased confusion at times with restless behavior at times. b. Under the section "Any new alternatives tried?" it was documented, "No." c. The plan was to continue to use the lap belt and roll belt secondary to increase confusion at times and restlessness. Not easily redirected. d. There was no indication that the restraints were being used to treat a medical symptom, nor was there an assessment for the low bed or the bed against the wall. Observation of Resident #4 on 7/21/03 at 1:50 p.m., revealed the following: a. The resident was in a low bed that had been placed in the comer of the room. b. Both side rails were in the up position in the middle of the bed. c. The resident was tied in the bed by the left side strap of a roll belt that was wrapped around his/her waist and tied to the side rail on both sides. d. The roll belt was not properly positioned around the resident's waist. e. A bed alarm was attached to the headboard. f. A long body pillow was on the right side of the resident near the wall, between the resident and the side rail. There was no mat on the floor next to the bed. h. The resident's call bell was out of reach of the resident. A Foley catheter bag was hanging off the left side of the bed and dragging on the floor, partially filled with urine. The resident stated, "No one comes to help you go to the bathroom!" The resident then asked the surveyor what was tied at his/her waist, pulling on the roll belt strap that was wrapped around his/her waist. The resident stated, "Why do I have this? I can't get out of the bed. I'll have to crawl over these,” pointing to the side rail. The resident then proceeded to kick off his/her blanket and attempted to get his/her legs out of 23. 24. 25. 26. 27. the bed, but his/her movement was restricted because his/her slacks were down around his/her ankles. A skin tear was observed on the resident's left knee and the resident was wearing an adult brief. Interview with the staff nurse who was standing outside the resident's door at the medication cart on 7/21/03 at 1:55 p.m., revealed: a. b. The resident was "tied up because she crawls out of the bed.” The nurse stated that the body pillow is "used to keep her in bed" but she "throws it." The nurse proceeded to look at the resident and indicated that the body pillow is placed on the left side of the resident between the resident and the side rai] so that she can't climb out of that side of the bed. When the nurse saw that the body pillow was on the resident's right side, the nurse stated that the resident must have moved it his/herself. The nurse then returned to her medication cart and did not assist the resident to the bathroom. A Certified Nurse's Assistant was found at 2:00 p.m. to assist the resident. The aide confirmed that the resident uses the bathroom for bowel movements. Observation of the resident on 7/22/03 at 8:50 a.m., revealed: a. The resident was alone in his/her room in a wheelchair with a waist restraint on that was criss-crossed behind the wheelchair and attached at the bottom of the chair. An alarm was clipped to the resident's sweater. The resident was observed pushing his/her feet into the wheelchair pedals and lifting his/her backside off of the chair several times in a row. The resident appeared uncomfortable in the wheelchair. At approximately 9:30 a.m., the resident was taken to physical therapy. Observation of the resident on 7/22/03 at 11:45 a.m., revealed: a. b. c. d. The resident was in the dependent dining room in his/her wheelchair with the waist restraint and wheelchair alarm on. The waist restraint was not released during the meal. At 12:32 p.m., the resident finished his/her meal and was taken to the TV lounge by an aide and left alone in the room. The waist restraint remained in place. Observation of the resident on 7/22/03 at 1:10 p.m. revealed that the resident was pulling at his/her waist restraint. “en TR: Tan ost RIEL 28. The resident asked the surveyor to remove the restraint and a. take him/her back to his/her room. b. The Activity Director was passing through the lounge and assisted the resident back to his/her room where he/she sat with him/her waiting for staff to return to the unit from the dining room to assist the resident. c. The resident stated, "Come on! Put me to bed!" d. The Activity Director wheeled the resident back to the TV lounge and left him/her there. e. Astaff person came to get the resident at 1:41 p.m. and put the resident back to bed. Observation of the resident on 7/22/03 at 2:45 p.m., revealed: a. b. The resident was in the low bed with the bed locked and up against the wall in the corner of the room. There was approximately a 4-inch space between the bed and the wall. The side rails were in the middle of the bed in the up position. c. d. The roll belt was around the resident and tied to the bed frame. There were no pads in the room to place on the floor next to the side of the bed that was facing the room. Observation of the position of the bed with 3 surveyors, 2 maintenance personnel and the Unit Charge Nurse revealed that the bed had to be moved out from the wall to raise it and get it out of the locked position. The Charge Nurse stated that she didn't know why the bed was against the wall. The Charge Nurse was asked to demonstrate how the side rails worked when the bed was in the low position. The nurse proceeded to lower the rails and they hit the floor as they were lowered and remained halfway up on the side of the bed. The maintenance staff confirmed that these were not the J. correct side rails for this bed, but not all of the low beds came with side rails so they used what they had when the nurses requested that they put them on the beds. k. The maintenance staff person removed one of the side rails from the bed. 29. Further observations of the resident on 7/22/03 throughout the 30 afternoon revealed that he/she remained in bed until dinnertime. Observation of Resident #4 on 07/22/03 at 5:45 p.m., revealed: a. The resident was in the dependent dining room in his/her wheelchair with the waist restraint on and an alarm attached to his/her sweater. b. The restraint was not released during the meal. 31. Interview with the Director of Nursing (DON), MDS (Minimum Data Set) Coordinator, and Unit Charge Nurse on 7/22/03 at 7:20 p.m. revealed the following: a. The DON was asked to explain why the Resident #4’s bed was pushed up against the wall and why the resident was being tied in bed with a roll belt. The DON replied that: i. There was not enough space in the room to place 2 floor mats on both sides of the bed, so the bed was put up against the wal] with one floor pad on the opposite side. ii. There were not enough floor mats to place them on both sides of the bed and that they were on order. iii, The only reason that the bed was in the left side corner was because of the layout of the room. iv. That they worked from the least to the most restrictive restraint with this resident after finding him/her on the floor with injuries and decided to put the bed against the wall on 7/10/03. vy. She could not explain why the team kept adding devices to the resident rather assessing which devices worked and discontinuing those that were not effective. vi. She stated that they were not aware that the bed against the wall was a restraint. vii. The DON confirmed that an assessment was not done for placing the bed against the wall and stated that she didn't know that it was required. The DON further stated that the staff had been instructed on the application of the roll belt and she would provide the survey team with the in-service education documentation. Interview with the Unit Charge Nurse revealed: i. That the staff did not walk the resident. ii. The resident was walked once a day by physical therapy and they were hoping that with therapy the resident would regain his/her strength and begin walking again. viii. 32, Interview with the MDS Coordinator on 7/22/03 at 7:35 p.m. revealed: a. b. That the fall committee met weekly and discussed falls and the restraints that were going to be used. The restraints are documented on the back of the fall assessment. Review of Resident #4's clinical record with the DON and the MDS Coordinator on 7/22/03, revealed that a Screening for 10 33. 34. 35. Fall Potential was completed on 6/6/03, but there was no documentation on the back of the form that indicated that the team had met and discussed the resident's restraints in relation to his/her falls. Interview with the resident's family member on 7/23/03 confirmed: a. That the resident was ambulating with a walker prior to breaking her arm. She said she came in one day and found the resident in a low bed with side rails. She said the staff told her that they do this after a fall. She confirmed that she signed a permission slip for the restraints about 1 to 2 weeks ago. She stated, "After 3 falls I didn't know what else to do.” She stated that the resident seemed calmer lately and she had questioned if the restraints were still necessary. She also stated that the resident was attending therapy and was now walking 25 feet with assistance and had 1 to 2 more weeks of therapy to go. In-service Training Report, provided to the survey team by the DON on 7/23/03 revealed the following: a. Conducted on 7/22/03 regarding in-services for the nurse's aides on how to apply the roll belt and other restraints and when to release the restraints. The in-services included information on not pushing beds up against the walls. The DON confirmed that she could not find any prior restraint in-service education session that had been given to the staff. Observation of the resident on 7/23/03 at 2:04 p.m. revealed: a. That the bed had been moved out from the wall and out from the corner of the room after the discussion with the survey team on 7/22/03. The bed was facing out into the room with the headboard near the wall. The inappropriate side rails had been replaced on the low bed and placed in the middle of the bed. The roll belt was tied loosely around the resident's waist, with enough space for the resident to slide down towards the end of the bed and out of the waist restraint. The restraint was tied to the bed frame. A long body pillow was placed between the resident and the side rail on the left side. There was no mat on the floor on the left side. 11 36. 37. 38. g. On the right side a second mattress had been placed on the floor next to the bed. h. A foam raised roll was next to the bed and not in use. Observation of Resident #4 on 7/23/03 at 3:55 p.m. revealed: a. The resident laying awake in the dark in bed. b. The restraints were in place as observed earlier in the day. The resident told the surveyor that he/she wanted to get up out of bed. . d. The surveyor went to find an aide to assist the resident. The aide went into the room and asked the resident what he/she c. wanted. f. The aide then walked out of the room. g. The resident began yelling, "Help me! Help me!" which could be heard in the hallway. h. The aide eventually returned to the resident's room to assist him/her to get up for the evening meal. Observation of the resident on 7/24/03 at 7:35 a.m. revealed: That the resident was up in a wheelchair in the depenclent .dining room eating breakfast. b. One strap of the restraint had been untied from the wheelchair and was lying on the floor. The restraint was not completely loosened around the resident's waist. a. Interview with the Activity Director on 7/24/03 revealed: That she has activities for low functioning residents at 10:00 in the morning after breakfast "when these residents are awake.” b. She confirmed that these residents are put back to bed after lunch and are sleeping in the afternoon, hampering afternoon activities with the residents. Review of Resident #4's Activity Record for July 2003 revealed that the resident attended morning exercise once during the month, attended hymns and devotionals twice during the month, attended sing along and music connection twice during the month, attended special entertainment 3 times and had outside strolls twice. d. It was documented that the resident refused to attend activities on 7/22/03 and 7/23/03. The resident was not observed attending any activity program during the 4 days of the survey. f. After breakfast the resident attended therapy, at noon she was medicated with psychoactive medications, and after lunch the resident was put to bed until dinnertime. a. 12 39. Observation of the resident on 7/24/03 at 9:45 a.m., in therapy revealed: a. The resident sitting in his/her wheelchair with the waist restraint completely removed and an over bed table in front of him/her placing blue pegs into a board. b. Interview with the Physical Therapist revealed he/she would walk approximately 60 feet "when he/she has a good clay.” The therapists confirmed that the resident was walking independently throughout the facility prior to his/her falls and fractures. B. Resident #10: 1. 2. Has a history of dementia and numerous falls. Observed on 7/21/03 through 7/24/03 in a wheelchair with a pelvic slide restraint crisscrossed in the back and tied down at the wheels of the chair. a. The resident was propelling him/herself throughout the facility by pushing him/herself along with his/her feet. b. His/Her position was noted that he/she sat on the edge of the wheelchair seat with his/her head resting on the back of the chair. c. A pelvic slide is to correctly position a person in an upright position while sitting, it goes around the waist and between the legs and is tied at the base of the wheelchair in the back, making it impossible for the resident to untie. According to the Occupational Therapy Assessment dated 6/20/02 he/she is able to follow simple instructions and is cooperative. His/Her Restraint Utilization Assessment dated 3/19/03 stated unable to use the merry walker, attempt to use a lap buddy. There was no documentation in his/her chart that a lap buddy was tried. a. Interview with the MDS Coordinator on 7/24/03 revealed: "We changed her restraint from the merry walker to the wheelchair with the pelvic slide in April.” b. According to the quarterly assessment of restraints it was February 26, 2003 that the pelvic slide was first introduced. a. Review of the clinical record revealed: a. The healthcare surrogate was not sent a letter when the resident’s restraint was changed from a merry walker to a pelvic slide and wheelchair. b. The only letter the healthcare surrogate received was dated 12/4/01 asking for permission to use the merry walker when up except for meals. 7. During an interview on 7/24/03 with the Director of Nurses, she stated: “It is our policy that a new restraint letter should be sent out when a restraint is changed." b. After that interview the facility brought the surveyor a letter, not dated, stating permission to: Inability to ambulate with merry walker. Pelvic slide in use to prevent sliding down in wheelchair. a. 8. Observation of Resident #10 on 7/23/03 at 12:40 p.m.: a. In bed with 2 large body pillows, one on each side, 2 side rails up, and his/her pants down around his/her ankles. b. This resident was not care planned for the use of body pillows. 9. Interview with the MDS (Minimum Data Set) Coordinator revealed: a. "The falls committee decides to use body pillows to keep the residents from falling out of bed." C. Resident #13: 1. On 7/21/03, during the initial tour of the facility, it was observed that Resident #13's bed was positioned against the wall. 2. Record review indicated: a. The resident had fallen on 7/9/03 with no apparent injuries. b. On 7/10/03, a note was made on the back of the Screening for Fall Potential sheet stating: "Move bed by wall and place mats on floor." 3. A bed positioned close against the wall is considered a physical restraint because it prevents the resident from voluntarily gettirig out of bed. 4. A Quarterly Addendum Restraint/Siderail Update was written in July 2003: a. The remarks were: wheelchair and bed alarms required. Forgets to ask for help. b. Recommendation: Continue with alarms. 5. There was no evidence in the clinical record that a restraint assessment had been done for the bed being placed against the wall. 4. Resident #11: 1. Observation on 7/23/03 at 2:15 p.m. revealed: a. The resident in a low bed with a scoop mattress. 14 b. One-half side rails were placed in the middle of the bed and in the up position. Mats were on the floor on both sides of the bed. d. Long body pillows were placed between the resident and the side rails on both sides partially covering the resident and restricting the resident's movement in the bed. a Observation of the resident at meals on 7/22/03 at approximately 11:45 a.m. and on 7/22/03 at approximately 5:30 p.m. revealed: a. That the resident was in the dependent dining room in his/her wheelchair with the Velcro belt on. b. The'belt was not released during either meal. _ Review of the resident's clinical record revealed that there was no order or restraint assessment for the use of the body pillows. _ Review of the Quarterly Addendum Restraint/Siderail Update revealed: a. That the form was completed in July 2003. b. The form lists the restraints used as: low bed with concave high side mattress, mats on floor, side rails up X 2, Velcro belt, bed and wheelchair alarm. The recommendation section stated, "No change." d. There was no assessment regarding the need for the restraints or documentation regarding whether the current restraints were necessary to treat medical symptoms. e. The goal was listed as "Continue to be free of injury.” 2 _ Review of the resident's Care Plan dated 8/16/01 with a target date of 6/19/03, revealed: a. That there was no Restraint Care Plan. b. Care Plan #1 for ADL's (Activities of Daily Living) listed the side rails, Velcro belt in wheelchair, low bed, bed alarm, pads on floor X 2 and wheelchair alarm under the "Needs/Problems" column. There were no approaches regarding these devices. d. Review of Care Plan #4 for "Potential for injury" dated 8/16/01 with a target date of 6/19/03, included the following approaches: i. "4. Side rails up X 2 when in bed. Low bed." i. "20. Velcro belt when in w/c. Release belt at meals and activities and q (every) 2 hours and reposition.” iii. "22. Concave Mattress with side elevation." iv. " 23. Mats on floor at bedside X 2.” y. "24. Bed alarm.” i. The approach: "Assess q (every) 3 months and as needed for restraint reduction and need," was "yellowed out" with discontinue date of 11/14/02 written next to this approach. © 15 6. Further review of the Care Plan revealed that it was not updated for the current restraints being used after the completion of the quarterly assessment on 6/19/03. D. Resident #7: 1. Observation on 7/22/03 at approximately 11:55 a.m.: a. Brought to the main dining room in his/her wheelchair. 2. At 12:25 p.m., surveyor asked a CNA (Certified Nurse's Assistant) to check on the waist restraint of this resident. a. The CNA checked and told the surveyor the clip belt for the waist restraint had not been released for the meal. b. The CNA released the belt after surveyor intervention. 3. During meal observations on 07/21/03 at approximately 12:30 p.m. and on 7/22/03 at approximately 5:30 p.m. to 7:00 p.m., it was observed that: a. Residents #1, #3, #4, #7, #10, and #18 did not have their waist restraints released for meals. b. All residents were care planned to have their waist restraint released during meals. 4. On 07/22/03 at approximately 4:00 p.m., 6:30 p.m. - 11 p.m. Certified Nursing Assistants were interviewed regarding restraint usage, restraint application and the placing of beds against the wall: The nurse's aides responded that they knew which residents get restraints by checking the list at the desk or reviewing the picture chart, which was hung on the residents' headboards. b. They also stated that the nurses told them which restraint to use. When questioned regarding the placement of the beds against the wall, the aides responded: i. Within the last 2 weeks, they came on duty and found some of the beds pushed against the wall. i. One aide stated, "It's silly to do it, it acts as a restraint." i. Another aide responded that the body pillows and floor mats are used for residents at risk of falls. a. 5. Review of the facility's Physical Restraints policy dated 1/2000 revealed: a. That the facility defined a physical restraint as "Physical restraints are any manual method or physical or mechanical device, material or equipment attached to adjacent to the resident's (patient's) body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Those products, which limit or deter the range of motion or the freedom to act on the part 16 of the resident. If a resident is able to apply or release a safety device by himself or herself, it would not be considered a restraint.” b. The policy further stated that the Restraint Committee will meet monthly after initial assessment to assess for the least restrictive device. c. Goal will be to be restraint free. d. The policy also stated that the Care Plan will show that the staff, in consultation with the resident or the legal representative, weighed the risks and benefits to the resident of using the physical restraint and that the staff developed, implemented and evaluated less restrictive solutions to manage the resident's problem. E. Resident #1: 1. Observation during the tour on 7/21 and throughout the days on 7/22/03 and 7/24/03 revealed: a. The bed of Resident #1 to be up against the wall on the resident's left side. b. The right side rail up. c. One long blue pad was near the bed but not positioned next to the bed. 2. Review of the resident's Care Plan revealed: a. The resident to be at risk for falls. b. Interventions included the low bed and matt but the residerit was not care planned to have the bed against the wall. F. Resident #12: 1. Observation on 7/22/03 at approximately 2:00 p.m. revealed: Resident sleeping in bed on his/her right side. The bed was tight against the wall on the resident's left side. Both side rails were up and the bed was in a low position. A blue matt was against the right side of the bed. On the bed with the resident was a long body pillow situated against the resident's left side. PAs op 2. Review of the resident's Care Plan revealed: a. When up, the resident will be in a Broda chair. b. While in bed the resident will be on a low bed mats at bedside with both side rails up. c. There was no Care Plan for bed against the wall or body pillows. 13. For this deficiency, AHCA provided the Respondent a mandated correction date of August 24, 2003. 17 14. The foregoing deficiency constitutes a Class II deficiency and warrants a fine in the amount of $5,000, to wit: (b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. Section 400.419 (3)(b), Florida Statutes (2003). 15. Based on the foregoing, Village on the Isle violated §483.25, Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Codes, herein classified as a Class II violation pursuant to §400.23(8), Florida Statutes, which also gives rise to conditional licensure status pursuant to §400.23(7)(b), Florida Statutes.” COUNT II VILLAGE ON THE ISLE FAILED TO ENSURE RESIDENTS RECEIVED CARE AND SERVICES TO PREVENT ACTIVE ASPIRATION OF FOOD AND FLUIDS § 483.25 (a-m), Code of Federal Regulations. (2003) Fla. Admin. Code R. 59A-4.106(4)(aa) (2003) 16. | AHCA repeats, re-alleges, and incorporates paragraphs one (1) through seven (7) as if fully set forth herein. 17. The regulatory provisions of the Code of Federal Regulations that are specifically pertinent here to Respondent and to operation of its facility as a long term care facility, which regulations are applied in Florida pursuant to Rule 59A-4.1288, Florida Administrative Code, include, but are not limited to, the following: 2 Southwest Florida Retirement Center, Inc. d/b/a Village on the Isle, Respondent, AHCA Case No. 2003006065, is the assignment of conditional licensure status case, pursuant to §400.23(7), Florida Statutes, [T]he Agency [AHCA] shall [emphasis added]... assign a licensure status of standard or conditional to each nursing home. ...(b) A conditional licensure status means that a facility, due to the presence of one or more class I or class II deficiencies, or class Ill deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with criteria established under this part or with rules adopted by the ugency. The burden of proof in a conditional licensure case upon the Agency is a preponderance of the evidence standard. 18 [42 CFR] Sec. 483.25 Quality of care. 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. A. Summary of Charges 18. During the annual survey conducted from July 21, 2003 through July 24, 2003 and based on observation, review of clinical records, administrative, nursing, and therapist staff interviews, the facility: a. Failed to ensure residents receive care and services to prevent active aspiration of food and fluids resulting in the inability to reach his/her highest physical and mental and psychological well being. B. Summary of Findings 19. The findings include the following: A. Resident #1: 1. Admitted to the facility on 3/5/03 with multiple diagnoses including Brain Disorder with VP Shunt Seizures, Syncope, Gastric Reflux Disease and Antral Fibrillation. 2. Observation during lunch on 7/21/03 from approximately 12:40 p.m. until 1:35 p.m. revealed the following: The resident was seated in the main living room, which was being used as the Dependent Dining Room at this time. b. The resident was seated in a wheelchair with a padded armrest on the left side. The lunch tray included spaghetti with 2 whole meatballs, whole Brussels sprouts, pudding thick milk and juice, and Italian ice. d. The meal ticket read the meat was to be ground into the meat sauce. The resident attempted to feed his/herself and was noted leaning severely to the left. f. The resident was holding food in his/her mouth. At approximately 12:52 p.m., the CNA placed a whole meatball in the resident's mouth. a. 19 h. At 12:55 p.m., the resident began coughing, choking, and gurgling. The resident spat out two large pieces of meatball and sneezed a large amount of mucous. The CNA continued to feed the resident offering large spoonfuls of pudding thick liquids and occasionally a large spoonful of Italian ice. k. During this time the resident occasionally coughed. The CNA did not wait for the resident to swallow nor did she encourage the resident to cough or clear his/her throat. m. The resident was then given 1/2 of a meatball. Again the resident started coughing and coughed out two marble size pieces of meatballs. At 1:13 p.m., the staff nurse interrupted the meal and gave the resident a Dilantin 100 mg. pill. i. She gave the pill in applesauce and offered approximately 3 ounce of a thin liquid supplement and left the room. The pill stayed on the resident's mouth for approximately five minutes until the resident finally swallowed what was left of the pill. —_ 5 ii. The CNA continued to assist the resident to eat and drink. From approximately 1:19 p.m. until 1:29 p.m., the resident held a mouth full of melted Italian ice in his/her mouth. The resident had a runny nose and was leaking fluids from his/her mouth. s. The resident would speak with a gurgling voice. t. The CNA repeatedly encouraged the resident to swallow but at 1:30 p.m. when the CNA asked the resident if he/she had swallowed the resident stated "no" and all the fluid rolled from his/her mouth. u. The resident began coughing and gurgling and the meal ended. At 1:35 p.m., the resident was placed in the hall front of his/her room and the staff nurse then checked the resident's mouth. . At this time the resident's mouth was clear and she was no longer coughing. . Observation of lunch on 7/22/03 at approximately 12:15 p.m. until 1:25 p.m. and supper on 7/22/03 at approximately 7:00 p.m. and breakfast on 7/23/03 revealed the following: a. The CNA was feeding the resident. b. The CNA continuously fed the resident without waiting for a swallow. The CNA would attempt to give fluids even though the resident's mouth was full. d. The resident would chew and cough at the same time. e. Liquids would ooze from the resident's mouth. 20 10. 11. f. At times the resident's eyes and nose were runny. . The resident was offered a health shake at both lunch and supper meals on 7/22/03 but neither time was it thickened. h. The resident was easily distracted and seated with 2 and 3 other residents. i. The resident would be looking around the room. The resident would attempt to talk and his/her voice was gurgling. The CNAs did not encourage the resident to clear his/her throat or ao: cough. Clinical record review revealed the resident was to be on a mechanical soft diet with nectar thick liquids, however the meal tickets and the meal tray were sent with pudding thick liquids. Review of the physician orders lacks an order for a downgrade in the resident's liquid consistency. Review of the CNA ADL (Activity of Daily Living) sheet reveal: a. The resident has been fully dependent in eating for the last four days. Prior to this, the resident only needed assistance. The resident has been taking only 25% to 50% of foods and fluids offered at meals the last seven days. Review of the resident's weight revealed he/she has lost 4.8 ponds in the last 4 weeks from 6/9/03 through 7/8/03. A fax sent to the physician 4/03/03 revealed: a. The physician desired gradual weight loss for this resident. b. However, the weight on 7/23/03, taken per surveyor request, revealed the resident to have lost greater than 4 pound since 7/17/03. c. Resident weight was 159.2 on 7/17/03 down to 154.8 on 7/23/03. Review of the clinical record lacks any type of monitoring of total calories or fluids consumed since the resident was taken off of tube feedings on 4/1/03. Review of dietary notes from 4/1/03 through 7/2/03 do not request a calorie or fluid count even though the resident is losing weight. A dietary progress note dated 4/30/03 reads: a. The resident is on pudding thick liquids. b. However, the last physician order dated 4/2/03 has the resident on nectar thick liquids. 21 12. Review of a Speech Pathologist note dated 5/ 1/03 revealed: a. ST tried the resident on pudding thick liquids. b. The note did not reveal whether the physician was aware nor was there a recommendation to the physician to downgrade to the pudding thick liquid. The note continues giving directions for resident's safe eating, including maximal cueing and Italian ice imbedded in pureed food to facilitate swallowing. 13. Occupational Therapist evaluation: a. b. Cc. Evaluated the resident on 3/6/03. Revealed therapist will be working on functional motor skills with the resident. The Occupational Therapist’s last note dated 5/22/03 reads: i. Care is now transferred to nursing. 14, An interview with the Occupational Therapist (OT) and Restorative Nurse on 7/23/03 revealed: 15. a. b. c. The OT stated she does not actually work with the residents swallowing and feeding technique. The OT's goal was to increase independent feeding. Interview with the Restorative Nurse revealed at times she will assist with feeding in the Dependent Dining Room but her main function was ambulating the residents. Both staff stated the Speech Pathologist is usually present Monday through Friday at breakfast time and roams between the Main and Dependent Dining Room. However, the Speech Pathologist was on vacation this week. The above meal observations were shared with the 2 staff members at this time. The OT stated the resident was to be on a pudding thick liquid for dysphagia and would see why the orders had not been changed. The OT and Restorative Nurse stated they would assist the resident at lunch today. Surveyor observation of Dependent Dining Room at approximately 1:30 p.m. a. b. c. The OT and Restorative Nurse were seated with the resident. The resident was through eating. The OT stated the resident could definitely not handle nectar thick liquids. The resident showed signs and symptoms of aspiration i.e. coughing. The OT stated fatigue was a factor and the longer the resident took to eat the slower the resident's swallowing capability but did not feel the resident's status had changed from the last time she worked with the resident. The OT stated she was not qualified to test the 22 resident for swallowing ability and would get an order for a speech therapy evaluation. A Speech Pathologist evaluated the resident during the evening meal on 7/23/03. i. The speech evaluation revealed the resident is not safe swallowing any consistency of liquid including pudding thick. Signs and symptoms of aspiration noted on all consistency including cough, wet coughed, choking and tearing of eyes. iii, The resident presented with severe oral pharyngeal dysphasia. iv. Speech therapy recommendations "NPO (nothing by mouth) with tube feed for nutritional and safety needs. D/T (Due to) family wishes continue with po (per mouth) diet of puree and pudding thick liquids..." 16. Review of the clinical record on 7/24/03: a. Lacks any documentation of what the family was actually told b. about the resident's condition. Neither speech therapy nor nursing staff documented whether or not the family is aware the resident is actually actively aspirating. 17. Interview with the Unit Manager and the DON on 7124103 a. b. Confirmed the lack of documentation Interview revealed the daughter of the resident was going to accompany the resident to the physician today but they would call her to make sure she understood the consequences of continuing to feed the resident. The Unit Manager called the daughter at this time and explained the speech pathology evaluation in detail including the risk of choking and filling the lungs with food and fluid. The daughter agreed not to feed the resident. The resident returned from the physician visit with new orders to maintain resident NPO and restart tube feedings. The DON revealed she had stayed last evening and in-serviced CNA on proper feeding techniques for Resident #1. A binder was put together for CNA staff to instruct specific feeding techniques for residents who have speech therapy instructions. 18. During the survey, the CNAs had no guidance as exhibited by the incorrect feeding techniques used on Resident #1 and the lack of skilled supervision for all residents in the Dependent Dining Room. B. Resident #8 1. a. Observation on 7/22/03 at 5:55 p.m.: Resident was eating dinner at the Restorative table in the Main Dining Room. 23 b. The resident had drunk her glass of juice and cup of coffee. c. He/She was observed picking up his/her empty glass several times and trying to drink from the empty glass. d. The staff in the dining room came over to the table throughout the meal but they did not offer the resident any additional juice during the meal and they were not observed cueing the resident to eat his/her meal. 2. Review of the resident's Care Plan #11, revised 7/3/03 a. Indicated that the resident was at risk for weight loss due to varied intake and confusion. b. The approaches included: i. Encourage intake to be at or above 50% or more most meals ii. Staff to assist resident at meals as needed iii. Encourage self-feeding and redirect to eating as needed during meals. Cc. Resident #20: 1. 7/22/03 at 6:28 p.m., observation of the evening meal for the first service, in the Naomi Dining Room 2. Certified Nursing Assistant (CNA) feeding, was observed to force fluids into the resident's mouth while he/she was still chewing his/her meal. 3. Resident #20 was identified on his meal ticket as Aspiration Risk. Dz. Observation of the Restorative dining table in the Main Dining Room on 722/03 and 7/24/03 1. During the noontime and evening meals, revealed no cueing for 8S (random sampled) Residents #27, #28, #29, and #30. 20. For this deficiency, AHCA provided the Respondent a mandated correction date of August 24, 2003. 21. The foregoing deficiency constitutes a Class Ii deficiency and warrants a fine in the amount of $5,000, to wit: (b) Class "II" violations are those conditions or occurrences related to the operation and maintenance ofa facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. Section 400.419 (3b), Florida Statutes (2003). 22. Based on the foregoing, Village on the Isle violated §483.25, Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Codes, 24 herein classified as a Class II violation pursuant to §400.23(8), Florida Statutes, which also gives rise to conditional licensure status pursuant to §400.23(7)(b), Florida Statutes? COUNT It VILLAGE ON THE ISLE FAILED TO ENSURE RESIDENTS RECEIVED ADEQUATE SUPERVISION AND ASSISTANCE DEVICES TO PREVENT ACCIDENTS § 483.25 (h)(2), Code of Federal Regulations (2003) Fla. Admin. Code R. 59A-4.1288 (2003) 23. | AHCA repeats, re-alleges, and incorporates paragraphs one (1) through seven (7) as if fully set forth his/herein. A. Summary of Charges 24. During the annual survey conducted from July 21, 2003 through July 24, 2003 and based on observation, review of clinical records, administrative, nursing, and therapist staff interviews, the facility: a. Resident #5 experienced 4 falls from 1/03 to 7/03 with a pelvic fracture resulting from a fall in 3/03. The facility continued to use siderails and a bed alarm as assistive devices to prevent accidents after his/her fracture even though it was documented that the resident was crawling out of the bottom of the bed and removing the bed alarm clip. b. Resident #11 who was at risk for falls due to a history of falls with injury and failure to use call system or ask for assistance did not have his/her bed alarm on as ordered when observed on 7/23/03. c. The facility's falls assessment and matrix procedure was not individualized and ineffective in preventing further falls in residents. 3 Ibid. 25 25. The regulatory provisions of the Code of Federal Regulations that are specifically pertinent here to Respondent and to operation of its facility as a long term care facility, which regulations are applied in Florida pursuant to Rule 59A-4.1288, Florida Administrative Code, include, but are not limited to, the following: Sec. 483.25(h) Quality of care. 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. x FF OF (h) Accidents. The facility must ensure that-- (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. B. Summary of Findings A. Resident #5: 1. Experienced 4 falls from 1/03 to 7/03 with a pelvic fracture resulting from a fall in 3/03. 2. Review of nurse's progress notes dated 1/2/02, 1/27/02, and 3/8/02 revealed that Resident #5 had experienced falls on these dates. a. On 1/2/03 at 8:30 p.m., the nurse's note revealed the resident was found on the floor with head resting on footrest of the wheelchair. b. The resident's back was red but no injury was noted. 3. The facility continued to use siderails and a bed alarm as assistive devices to prevent accidents after his/her fracture even though it was documented that the resident was crawling out of the bottom of the bed and removing the bed alarm clip. a. Review of the Quarterly Addendum Restraint/Side Rail Update dated 1/16/03 noted that the facility continued to use side rails and a wheelchair pad monitor was added secondary to being found on the floor on 1/2/03. b. On 3/21/03 at 6:40 a.m., the nurse's progress note documented that the resident was found lying on his/her side on the bathroom floor. It was noted that the resident removed the bed alarm and ambulated to the bathroom. A 2-centimeter skin tear was noted on the resident's right elbow and the resident complained of hip pain at 7:05 a.m. i. ii. 26 iii. The resident was sent to the emergency room at 9:55 a.m. for a hip x-ray and found to have a pelvic fracture. The Quarterly Addendum Restraints/Side Rail Update dated April 2003 indicated: i. Continued non-compliance by the resident with asking for assistance. There was no documentation that the team discussed the use of other devices, such as a low bed, to prevent further falls with injury. The recommendations were to continue the use of the 2 side rails and a bed and wheelchair alarm. Resident's Care Plan revealed that the fall was noted and the intervention of "toilet upon arising, after meals, HS (hour of sleep) and PRN (as needed)" was added. i. There were no additional approaches added nor was a change in the assistive devices considered even though the bed alarm and side rails remained ineffective in preventing falls. ii. iii. 4. Review of the RAP (Resident Assessment Protocol) for falls dated 4/3/03 indicated that the resident now requires total staff assistance and uses a Geri chair for comfort following the fall. It was noted that the resident was at risk for further injury related to decreased safety awareness and unaware of limitations. 5. Review of Care Plan #7 for Resident # 5, updated 4/3/03, indicated: a. b c. d Resident at risk for falls secondary to history of falls; Requires staff assistance for transfers; Does not always ask for assistance. The interventions included a bed alarm and a Geri chair for positioning and comfort. The approaches included: frequent observation, remind to use call system, scheduled toileting, remind to ask for assistance with constant cues. 6. The Physical Therapy Evaluation dated 4/9/03 indicated that Physical Therapy was not recommended because the resident had "poor" rehabilitation potential. 7. The nurse's progress notes dated 5/2/03 at 4:45 a.m. revealed: a. b. c. d. Resident climbed out of the bottom of the bed; Attempted to stand and was unable to without assistance. The resident was found laying her back. It was noted that the resident stated that he/she removed the bed monitor clip from his/her gown. 27 The resident was placed back in bed with the bed monitor reapplied. The staff noted that they encouraged the resident to use the call bell. 8. The nurse's progress notes dated 7/16/03 at 4:30 a.m. documented: a. b. Resident #5 was found lying on his/her back in the bathroom. It was noted that the resident stated that he/she had to urinate and lost his/her balance. It was also noted that the bed monitor was attached to the resident's gown. i. The mattress alarm did not ring; ii. The resident had crawled out of the foot of the bed. The nurse documented that the nurse reminded the resident to use his/her call light. There was no documentation regarding the staff checking the functioning of the mattress alarm before placing the resident back to bed. 9. Nursing/Rehabilitation Communication Form dated 7/16/03, addressed to the Physical and Occupational Therapists requested: a. b. A recommendation regarding the resident's fall. The nurse noted the fall on 7/16/03 at 4:30 a.m. It was noted, “all ready has bed against wall", "mattress alarm" and "side rails up." The recommendation from the Registered Physical Therapist was "Continue above set-up. Recommend PT (Physical Therapy) evaluation." Further review of the Care Plan revealed: The fall of 7/16/03 was not addressed and no additional interventions were added. There was no indication in the Care Plan that therapy was begun. i. ii. 10. Quarterly Addendum Restraint/Side Rail Update dated July 2003 indicated: a. Resident "Continues to attempt to get out of bed." b. d. The recommendation: i. Continue to have side rails up X 2; ii. Continue bed monitor; iii. Continue cues to ask for assistance; iv. Continue wheelchair monitor when up in wheelchair. There was no documentation that alternate assistive devices were discussed or attempted even though the current devices were ineffective. The next evaluation was scheduled for October 2003. 28 11. Observation of the resident on 7/23/03 at approximately 2:00 p.m., revealed: a. Resident was in a regular height bed with full side rails up X 2. b. The bed was close to the wall. c. Every time the resident moved in bed, the mattress alarm sounded. d. The resident stated, "Can't they tum this thing off, it keeps me up all night!" When the nurse responded to the alarm, he/she stated that the resident did not weigh enough for the alarm to work properly. ig Resident #11: 1. Was at risk for falls due to a history of falls with injury and failure to use call system or ask for assistance did not have his/her bed alarm on as ordered when observed on 7/23/03. a. Observation of Resident #11 on 7/23/03 at 2:15 p.m. revealed: i. Resident in bed. ii. His/Her bed alarm was not attached and was lying on the table next to the bed. b. Review of the 7/03 physician orders revealed: i. A bed alarm was ordered for the resident. ii. Review of the Resident #11's Care Plan #4, which addressed potential for injury secondary to history of falls indicated that a bed alarm was one of the approaches that the facility was using for fall prevention. The facility's falls assessment and matrix procedure was not individualized and ineffective in preventing further falls in residents. Interview with the Director of Nursing (DON) and the MDS (Minimum Data Set) Coordinator on 7/22/03 revealed: 1. The facility had begun to work on a "Falls Project" in 6/03. 2. The Director of Nursing stated that their initial plan was to implement specific assistive devices after the first, second, and third falls. 3. The DON then stated that after discussion with the survey team, they realized that this wouldn't work because the approaches had to be "individualized" for each resident. 4. The DON stated that the team met weekly to discuss falls but had not been documenting their meetings. 5. She further stated that they just began writing notes on the back of the Screening for Falls Potential form regarding what interventions they would use. 6. Review of the back of the forms for Residents #5 and #11 revealed that they were blank. 29 For this deficiency, AHCA provided the Respondent a mandated correction date 26. of August 24, 2003. 27, The foregoing deficiency constitutes a Class Ill deficiency and warrants a fine in the amount of $5,000, to wit: (b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. Section 400.419 (3)(b), Florida Statutes (2003). 28, Based on the foregoing, Village on the Isle violated §483.25, Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Codes, herein classified as a Class II violation pursuant to §400.23(8), Florida Statutes, which also gives rise to conditional licensure status pursuant to §400.23(7)(b), Florida Statutes.* COUNTIV. 29. AHCA repeats, re-alleges, and incorporates paragraphs one (1) through seven (7) as if fully set forth his/herein. A. Summary of Charges 30. During the annual survey conducted from July 21, 2003 through July 24, 2003 and based on observation, review of clinical records, administrative, nursing, and therapist staff interviews, the facility: a. Failed to ensure that the resident's ability in activity of daily living does not diminish. This is evidenced by 1 (Resident #10) of 17 active sampled residents not receiving appropriate treatment to maximize the resident's functional abilities. * Ibid. 30 B. Summary of Findings 31. The findings include the following: A. Resident #10: 1. Observed on 7/23/03: a. Resident #10 was observed self-propelling his/herself through the facility in his/her wheelchair with a pelvic slide in place. b. The pelvic slider was to be used for positioning, however the resident was observed sitting on the edge of the wheelchair with his/her head resting on the back of the chair. 2. Review of the Quarterly Addendum Restraint/Side Rail Update/Lap Buddy for January 2003 it states: a. Resident #10 ambulates throughout the facility with merry walker. b. The goal states to continue use of the merry walker and to promote independent ambulation, no falls, no injury. 3. The nurse's notes read the resident ambulates with the merry walker throughout the facility and in and out of other residents’ rooms. 4. Resident #10's MDS dated 11/6/02 noted 0-1 for ambulation denoting independent ambulation. 5. Quarterly Addendum Update for February 2003 stated: a. Decreased ambulation poss. second to dementia. b. Asses use of wheelchair with clip belt. c. The goal was to prevent injury. 6. Weekly summary dated 2/22/03 reads: a. Needs assist of one for ambulation, b. The resident is no longer using merry walker re: difficulty transferring him/her-re: refusing to stand to transfer. 7. Nurse's notes dated 2/26/03 stated: a. Resident up in w/c (wheelchair) at nurses station. b. Slipped down in w/c under safety belt onto floor. c. No apparent injuries. 8. Quarterly Addendum Update dated 2/26/03 stated: a. Slide out of w/c with clip belt. b. Assess the use of pelvic slide (this is a restraint that goes around the waist and through the legs to keep a person upright when sitting). c. Goal prevent sliding. 9. The doctors order for 3/19/03 read: a. Pelvic slider when up in w/c for proper positioning. b. D/C (discontinue) merry walker R/T inability to ambulate in merry walker. c. Decrease safety awareness diagnosis dementia. 10. Restraint Utilization Assessment dated 3/19/03 stated: a. Restraint presently used was a pelvic slider, b. Unable to use merry walker, 31 ll. 18. 19. c. Attempt to use lap buddy. d. Consideration stated: i. Has used merry walker for independent ambulation. ii. Unable to use merry walker - decline in condition possible improvement, and to check activity notes. Activity notes for 1/28/03 state resident attends several out of room activities. f. Activities notes for 4/21/03 state resident has a decrease in attendance in activities, but still escorted to several. The Quarterly Addendum Update dated 3/19/03 stated: a. Pelvic slider, effective, b. Recommend continued use. The restraint evaluation dated 4/4/03 for the pelvic slider states: a. The resident continues to slide down toward edge of w/c. b. Any new alternatives tried? No. c. Continue restraint use? Yes d. Reason: Maintain proper position prevent sliding. The Quarterly Addendum Update dated April 2003 stated: a. No adverse effects from use of pelvic slider, b. Continue use. The Weekly Assessments dated 4/5/03, 4/12/03, 4/19/03, noted: a. Unable to ambulate. The MDS dated 4/22/03: a. Showed a significant change in ambulation to 8-8 (total dependence). The weekly summary dated 5/17/03, and 5/25/03 noted: a. Ambulation needs assistance of two. The Quarterly Addendum Update for July 2003 states: Independently propels w/c up & down hallway with no apparent purpose. b. Pelvic slider effective. The weekly summaries dated 6/8/03, 6/15/03, 6/22/03, 7/6/03, 7/13/03, and 7/20/03 show: a. Inability to ambulate. Occupational Therapy (OT): a. 6/18/03, initial assessment due to recent numerous falls when getting out of bed without assistants, treatment in merry walker, according to nursing. b. Cognition listed: follows simple instructions. 6/20/03, OT listed its role to be mainly to try various techniques with this resident and recommend techniques and equipment to nursing staff. d. 6/26/03, the OT assessment read: i. Resident seen by OT for skilled treatment/instruction in safe transfers and positioning. a. 32 Safety awareness/ADL safety, and strengthening/active range of motion. iti. Minimal retention of instruction demonstrated. iv. A program for the resident has been written up for restorative nursing. The progress note from OT from 6/20/03-6/26/03 states: On 6/24/03 at 2:30 p.m., resident found standing in doorway of room with one foot in his/her trousers, which were dragging behind him/her. Resident assisted back to bed where the rails were up and in place. His/her bed had not been lowered to the floor and his/her bed alarm was not activated. f. 6/26/03, resident had been seen by OT for safe transfers and positioning instruction. Due to dementia, minimal retention of instruction was demonstrated. ii. The resident follows direction well. ili. OT is now able to make recommendations to the nursing staff to increase his/her safety and reduce his/her falls. iv. Resident ambulates or sits in a merry walker, reportedly fell in that. (No documentation was found to verify this.) Plan: Discharge from OT with recommendations to the nursing staff to increase resident safety and decrease falls. The Restorative Program Plan instructions dated 6/26/03 state: Ambulate patient from seat in dining room to merry walker using a walker with assistance as needed. h. From 7/21/03-7/24/03 the resident was observed: In a wheelchair with a pelvic slider on propelling his/herself throughout the facility. The pelvic slider did not keep the resident from sliding as he/she was observed sitting on the edge of the w/c with his/her head leaning back. iti. During all meal observations done during the survey the resident was never repositioned to an upright positior:. iv. On 7/23/03, his/her merry walker was located in the corner of his/her room and his/her walker was leaning against the dresser, the resident was never put in the merry walker, nor was he/she walked in the dining room during the survey. Interview with the MDS Coordinator on 7/23/03 revealed: a. In April, due to a change in condition, it was required to change the resident from a merry walker to a w/c. Interview with the Occupational Therapist on 7/24/03 she stated: a. The instructions given to the nursing staff are not documented. Review of chart revealed: ii. i. li. iii. i. il. 33 a. A letter dated 12/4/01 to the legal representative asking for permission to use a merry walker as a restraint except during meals. b. In an interview with the Director of Nursing on 7/24/03, she stated that there should be another letter sent out when there is a restraint change. c. At 11:00 a.m., the MDS Coordinator brought this surveyor an undated letter letting the legal representative know that due to inability to ambulate with merry walker pelvic slide in use to prevent sliding down in w/c. For this deficiency, AHCA provided the Respondent a mandated correction date 32. of August 24, 2003. 33. The foregoing deficiency constitutes a Class II deficiency and warrants a fine in the amount of $5,000, to wit: (b) Class "II" violations are those conditions or occurrences related to the operation and maintenance of a facility or to the personal care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of the facility residents, other than class I violations. The agency shall impose an administrative fine for a cited class II violation in an amount not less than $1,000 and not exceeding $5,000 for each violation. A fine shall be levied notwithstanding the correction of the violation. Section 400.419 (3)(b), Florida Statutes (2003). 34. Based on the foregoing, Village on the Isle violated §483.25, Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Codes, herein classified as a Class II violation pursuant to §400.23(8), Florida Statutes, which also gives rise to conditional licensure status pursuant to §400.23(7)(b), Florida Statutes.” DISPLAY OF LICENSE Pursuant to §400.25(7), Florida Statutes, Village on the Isle shall post the conditional license in a prominent place that is a clear and unobstructed public view where residents are being admitted to the facility. Copies of the conditional licenses are attached hereto as Exhibit “A” and Exhibit “B” and the standard license subsequent hereto is attached as Exhibit “C”. 5 Ibid. 34 CLAIM FOR RELIEF WHEREFORE, AHCA demands the following relief: 1. Enter factual and legal findings as set forth in the allegations of Counts I, II, I, and IV. 2. Assess a fine in the amount of $5,000.00, for each of the referenced violations for a total of $15,000.00. 3. Enter factual and legal findings in favor of the Agency on Counts I, I, Ill, and IV such that a conditional license is upheld. 4. Grant such other relief as the Court deems is just and appropriate. Submitted on this ZA 3 day of September 2004. Respectfully submitted. Eric R. Bredemeyer Fla. Bar. No. 318442 Senior Attorney Agency for Health Care Administration Office of the General Counsel 2727 Mahan Drive Ft. Knox, Building #3, MS #3 Tallahassee, FL 32308 (850) 922-5873 NOTICE The Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Explanation of Rights (one page) and Election 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. 35 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a copy his/hereof has been furnished to Administrator, Southwest Florida Retirement Center, Inc. d/b/a Village on the Isle at 910 South a veri 5g (lg OPE Tamiami Trail, Venice, FL 34285, Return Receipt No. Fog312l03200 97 GY US. Certified Mail and the Registered Agent for Southwest Florida Retirement Center, Inc. at 920 Tamiami Sepden ber Trail South, Venice, FL 34285 on this < ¢ day of Aygust 2004. \ PH 3 0/0 0000 FF ors ee Eric R. Bredenieyer, Esquire 36

Docket for Case No: 04-003843