Ty ee a STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ADMINISTRATION, 7LOb 4575 L294 e049 4552 AGENCY FOR HEALTH CARE Certified Article Number | ie 04 Petitioner, SENDERS RECORD vs. AHCA No. 2004007271 (Cond. Lic.) AHCA No. 2004007270 (Fine) Q@ = b oe DESTIN HEALTH CARE In, sar ASSOCIATES, LLC, d/b/a SE: “gp Ss Me) DESTIN HEALTHCARE AND CE ay Xs REHABILITATION CENTER, Cor Lae a 7 —tIf\ VO! ; 7 Respondent. oe C | \O PS / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (“AHCA” or “A gency”), by and through the undersigned counsel, and files this Administrative Complaint against DESTIN HEALTH CARE ASSOCIATES, LLC, d/b/a DESTIN HEALTHCARE AND REHABILITATION CENTER (“Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose conditional licensure status upon Respondent, pursuant to Section 400.23(7)(b), Florida Statutes, and an administrative fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500) upon Respondent, pursuant to Section 400.23(8)(b), Florida Statutes. Administrative Complaint 2004007271 & 2004007270 Page 1 of 9 JURISDICTION AND VENUE 2. Pursuant to Sections 120.569 and 120.57, Florida Statutes, upon a request for formal hearing, AHCA and the Division of Administrative Hearings have jurisdiction. 3. Venue shall be determined pursuant to Rule 28-106.207, Fla. Admin. Code. PARTIES 4. AHCA 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; and Chapter 59A-4, Fla. Admin. Code, respectively. 5. Respondent, DESTIN HEALTH CARE ASSOCIATES, LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, DESTIN HEALTHCARE AND REHABILITATION CENTER (“Facility”), is a 119-bed nursing home located at 195 Mattie M. Kelly Boulevard, Destin, Florida 32541. Respondent is licensed as a skilled nursing facility, having been issued licensed number 16210961. Asa licensed facility under the licensing authority of AHCA at all times material hereto, Respondent was required to comply with all applicable regulations, statutes and rules. COUNTI CLASS Il ISOLATED VIOLATION FOR FAILURE TO ENSURE RESIDENT RECEIVED ADEQUATE SUPERVISION TO PREVENT AN ACCIDENT 42 CFR 483.25(h)(2) Section 400.23(7)(b), Florida Statutes Section 400.23(8)(b), Florida Statutes Rule 59A-4.1288, Fla. Admin. Code Administrative Complaint 2004007271 & 2004007270 Page 2 of 9 6. AHCA te-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 7. The regulatory provision of the Code of Federal Regulations that is pertinent to this alleged violation reads as follows: 42 CFR 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. ORK (h) Accidents. The facility must ensure that — KE (2) Bach resident receives adequate supervision and assistance devices to prevent accidents. 8. AHCA surveyors conducted a survey of Respondent’s facility on February 5, 2004, which revealed the following: The facility failed to ensure one of 25 sampled residents received adequate supervision to prevent an accident, which resulted in the resident sustaining a fractured hip (Resident #12). Specific findings were: a). Review of the clinical record on Resident #12 revealed he/she was admitted to the facility on 1/13/03 with multiple diagnoses, which included in part, Parkinson’s Disease, Confusion, Osteoporosis, and Organic Brain Syndrome. According to admission interviews, the resident had previously resided in a nearby Assisted Living Facility but was no longer able to live in this environment due to his/her unsteady gait and poor safety awareness resulting in frequent falls. The initial Minimum Data Set (MDS) assessment completed on 1/28/03 assessed the resident as having had a fall within the previous 30 days, unsteady gait, and having moderately impaired cognitive skills with poor decision making and requiring cues and supervision. A fall risk assessment completed on 1/14/03 assessed the resident as having intermittent confusion, being unaware of safety related limitations, having balance problems while standing and/or walking, being unstable when making turns, requiring the use of assistive devices to transfer or ambulate, and becoming unstable after transferring him/herself. The resident’s history of falls is described as “having one-two falls in the past three months.” A care plan developed on 1/29/03 identified Resident #12 as being “at risk for falls due to Parkinson’s, dementia with confusion and recent falls...frequently was to clean and bend over to pick items up from floor risking falls.” Various approaches were developed to minimize and reduce the risk factors that could cause falls including “Cue and re-direct (as needed) for safety, help make appropriate decisions and judgments; and apply a soft waist restraint while in bed.” Administrative Complaint 2004007271 & 2004007270 Page 3 of 9 Updates and revisions to the care plan indicate the resident fell from bed to floor on 5/8/03 and he/she was placed on the facility “Failing Star Program.” b). A resident summary completed on 7/2/03 describes the resident as being confused, frequently loses train of though in conversation, requires assistance to the bathroom and requires safety devices due to poor safety awareness. An MDS assessment completed on 7/11/03 assesses the resident as requiring a one-person physical assist for transfers on/off toilet. c). Further review of the record revealed that on 9/15/03 at approximately 9:50 p.m., the resident was assisted to the toilet by his/her Certified Nursing Assistant (CNA). After asking the resident to sit on the toilet while she went to get a washcloth, the CNA left the resident unsupervised and returned to find him/her lying on the floor in the bathroom doorway. Upon examination, it was determined the resident sustained a bruise to the upper back and a raised area to the curve on the spine. The resident was described as being alert and confused and was complaining of pain in the back, right elbow and other various parts of the body. The resident’s pulse was elevated and his/her blood pressure was low and the physician was notified and gave orders to send him/her to the emergency room for evaluation. At approximately 4:30 a.m. on 9/ 16/03, the resident returned to the facility with a diagnosis of a fracture of the right lesser trochanter of the femur. d). During interview on 2/5/04 at approximately 9:45 a.m., the facility Risk Manager confirmed that following a complete investigation, the accident was determined to be avoidable, stating “if the CNA had been where she was supposed to be, it wouldn’t have happened.” 9. Respondent’s failure to ensure that the resident received adequate supervision to prevent an accident is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.25(h)(2). 10. AHCA classified the nature and scope of this violation as a class II “isolated” violation. Pursuant to Section 400.23(8)(b), this classification constitutes grounds for the imposition of an administrative fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500). A class II violation is defined as one that “the agency determines 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.” Id. Administrative Complaint 2004007271 & 2004007270 Page 4 of 9 11. Respondent’s failure to ensure that the resident received adequate supervision to prevent an accident constitutes grounds for the imposition of conditional licensure status, pursuant to Section 400.23(7)(b). CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Uphold the imposition of conditional licensure status. 3. Impose an administrative fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500). 4. Such other relief as this Court deems is just and proper. DISPLAY OF LICENSE Pursuant to Section 400.23(7)(d), Florida Statutes, Destin Healthcare and Rehabilitation Center shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License is attached hereto as Exhibit “A”. Administrative Complaint 2004007271 & 2004007270 Page 5 of 9 -_ i a 2 ar NOTICE My . 7 oO 2 Aogiiis, My Respondent is notified that it has a right to request an administrative he iam of "lo 4p, aD Section 120.569 and 120.57, Florida Statutes. Specific options for administrative Os 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 Agency for Health Care Administration, and delivered to: Agency Clerk, Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida, 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE AGENCY MUST RECEIVE A REQUEST FOR HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT BY RESPONDENT. FAILURE TO COMPLY WILL CONSTITUTE AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND RESULT IN THE ENTRY OF A FINAL ORDER BY THE AGENCY, Respectfully submitted this 1 day of __{ ae) 2004. 4 ur Donna La Plante, Esquire Assistant General Counsel Fla. Bar No. 0966193 Counsel for Petitioner Agency for Health Care Administration 2727 Mahan Drive, Building #3, MSC #3 Tallahassee, FL 32308 (850) 922-5873 (office) (850) 413-9313 (fax) Administrative Complaint 2004007271 & 2004007270 Page 6 of 9 CERTIFICATE OF SERVICE CERTIFICATE OF Sau AHCA, by and through its undersi gned counsel, hereby certifies that a true and correct copy of the foregoing Administrative Complaint, with an Election of Rights for Administrative Hearing form and an Explanation of Rights Under Section 120.569, F.S.A. form, have been forwarded by certified mail, return receipt requested, to: Tony Rimmer, Administrator, Destin Heallficare and Rehabilitation Center, 195 Mattie Kelly Boulevard, Destin, Florida 32541, this 1 aay of Od 2004. DOK Donna La Plante, Esquire Assistant General Counsel Administrative Complaint 2004007271 & 2004007270 Page 7 of 9 Exhibit “A”

Docket for Case No: 04-004050