STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION cM TEC 20 Dp: Sy AGENCY FOR HEALTH CARE ADMINISTRATION, i Po Petitioner, AHCA No.: 2004008448 Return Receipt Requested: Vv. 7003 1680 0006 9825 7512 7003 1680 0006 9825 97529 MARATHON MANOR, INC. d/b/a MARATHON MANOR, Respondent. O U “ U KO A ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against Marathon Manor, Inc. d/b/a Marathon Manor (hereinafter “Marathon Manor”) pursuant to Chapter 400, Part II and Section 120.60, Florida Statute, (2004) and hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $10,000.00 pursuant to Sections 400.23(8) (b), Florida Statutes. JURISDICTION AND VENUE 3. This court has jurisdiction pursuant to Section 120.559 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. 4. Venue lies in Monroe County, pursuant to Section 400.121 Florida Statutes and Chapter 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 6. Marathon Manor is a skilled nursing facility located at 320 Sombrero Beach Road, Marathon, Florida 33050 and is licensed under Chapter 400, Part II, Florida Statutes and Chapter 59A-4, Florida Administrative Code. COUNT I MARATHON MANOR FAILED TO ENSURE THAT APPROPRIATE AND TIMELY CARE AND SERVICES WERE PROVIDED TO A RESIDENT WHO HAD FALLEN AND SUSTAINED FRACTURES ULTIMATELY RESULTING IN THE DEATH OF THE RESIDENT. TITLE 42 SECTION 483.25 CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE RULE 59A-4.106 (4) (aa), FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 7. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. &. Because Marathon Manor participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 Code of Federal Regulation 483. 9. An unannounced licensure and recertification survey was conducted 8/2/04 through 8/5/04. Based on interview and record review the facility failed to ensure that appropriate and timely care and services were provided to a resident who had fallen and sustained a fracture to the left hip and three left ribs ultimately resulting in death for one (1) out of 19 sampled residents, #14. The findings include the following: 10. A review of the clinical record for Resident #14 revealed the following diagnoses: CVA and fracture of neck of femur. According to the latest assessment dated 4/15/04, the resident was independent with decision-making ability. The resident was also independent with transfers and continent of bowel and bladder. A review of the nurses' notes dated 6/20/04 revealed that a Certified Nursing Assistant (CNA) found the resident lying on the floor face down. The facility called 911 but the resident refused to go to the hospital. Nurses' notes on 6/22/04 indicated that the resident was complaining of constant pain, and had difficulty explaining due to a language barrier. The notes continued to state that the resident's color was very ashen, with dark circles under his/her eyes, very weak, complaining of left sided rib pain when up in wheelchair. The notes further stated there was increased confusion, incontinence of urine at times and refusal to allow staff to provide incontinent care or change his/her wet clothes. "Will have note for Dr. (name) to see resident when he/she visits on 6/23/04.” However, there was no indication that the staff attempted to ask the resident if he/she would go to the hospital based on the above assessment. 11. The nurses' notes on 6/24/04 stated that the resident appeared to be declining rapidly, refusing to eat, complaining of nausea, vomiting and pain. The notes continued to state that the facility was making arrangements to transfer the resident to the hospital but the resident refused. At 1:30 PM, the nurses! notes stated that the resident was now having periods of unresponsiveness. The resident then decided to go to _ the hospital according to a Spanish speaking CNA. 12. During an interview with the Care Plan coordinator on 8/5/04, she confirmed that there was no documentation that the facility had attempted to convince or counsel the resident on the importance of going to the hospital after the fall, other than on the day of the fall (6/20/04). In addition, there is no indication that a staff member who was able to communicate with the resident in Spanish spoke with him/her during the four (4) days the resident was in the facility after the fall. It was brought to the attention of the Care Plan coordinator the nurses! note dated 6/24/04 when the nurse had stated that the resident’s color was ashen. She had no comment. 13. A review of the hospital emergency physician record revealed that the resident's pulse oximetry reading (a noninvasive method of continuously tracking oxygen saturation) in the field was 60-70% (normal is 95-100% for adults). The resident had tenderness upon left hip rotation and pain in left rib cage. According to the emergency room notes, the resident had a left hip fracture and left rib fractures 7, 8, and 10. Progress notes dated 6/25/04 by the orthopedic physician stated that the resident was not medically stable at that time for surgery. The resident died in the hospital on 6/26/04 at 9:08 PM. 14. Based on the foregoing facts, Marathon Manor violated 483.25, Code of Federal Regulation as incorporated by Rule 59A- 4.1288, Florida Administrative Code and Rule 59A-4.106(4) (aa), Florida Administrative Code herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries an assessed fine of $2,500.00. However, the fine is doubled due to the citing of a Class II violation during the survey of June 25, 2004 and June 26, 2004 thereby totaling $5,000.00. COUNT IIT MARATHON MANOR FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT ACCIDENTS. TITLE 42 SECTION 483.25 (h) (2),CODE OF FEDERAL REGULATIONS RULE 59A-4.1288, FLORIDA ADMINISTRATIVE CODE (QUALITY OF CARE) CLASS II 15. AHCA re-alleges and incorporates (1) through (5) as if fully set forth herein. 16. An unannounced licensure and recertification survey was conducted 8/2/04 through 8/5/04. Based on interview and record review the facility failed to provide adequate supervision to prevent accidents for three (#9, #13 & #14) out of 19 sampled residents. The findings include the following: 17. A review of the clinical record for Resident #13 revealed the resident was admitted to the facility with diagnoses of dementia, aortic stenosis, hypertension, diabetes, mitral valve regurgitation and coronary artery disease. A review of the Minimum Data Sets with reference dates of 2/26/04 and 5/25/04 revealed the resident was coded "1" for "Balance while sitting-position, trunk control" indicating "unsteady, but able to rebalance self without physical support." The "Functional limitation in range of motion" for the "arm - including shoulder or elbow" and "hand including wrist or fingers" is coded "1/1" indicating "limitation on one side" and "partial loss." The coding for "leg including hip or knee" and "foot including ankle or toes" is "2/1" indicating “limitation on both sides" and "partial loss." A review of the Resident Assessment Protocol Guide for Activities completed on 9/2/03 stated that the resident needs physical assistance getting to and from activity areas because, "(resident's name) needs assistance with w/c (wheelchair) to location." A review of the monthly nursing summaries for 12/03, 1/04 and 3/04 under wheelchair mobility stated, "propels self backwards." A review of the resident's care plan dated 9/2/03 and most recently updated on 5/25/04 revealed, "Resident requires total assistance with dressing and personal hygiene, extensive assistance with transfers and mobility." The same care plan also stated the following "Need/Problem/Concern, "Potential for falls due to decreased mobility, Bell's Palsy with some paralysis & weakness. Resident non compliant with transfers. Last fall 3/3/03. Resident found lying on floor in front of w/c (wheelchair) with no injury." The following approaches were listed for preventing falls: a. Call bell in reach at all times. b. Resident on falling star program. (A fall prevention program) c. Assist resident with transfers. d. Check on resident frequently for position & safety. e. Remind resident of safety issues. 18. A review of the Nurse's Notes on Resident #13 dated 2/26/04 revealed the following entry: "Heard crying out 'I need help' and was found on floor between bed & bedside table on (his/her) left side. Assisted back to bed & checked for injuries. 2 small abrasions on left knee noted. No other marks noted at this time." A review of the Nurse's Notes dated 6/26/04 revealed the following entry: "Summoned to outside of building by visitor - resident was laying on left side with bump on left forehead & skin tear on left elbow, wheelchair was laying on side. Resident was responsive when asked his name. B/P (blood pressure) 130/82 P (pulse) 78 R (respirations) 20 T (temperature) 98.2. 911 called to take resident to hospital for observation." 19. A review of the radiological interpretation for the CT scan of the head performed on resident #13 while in the emergency room on 6/26/04 stated, "There is a large right sided subdural hematoma which exhibits increased density indicating an acute process. This process extends over the frontal, parietal, and occipital regions. It is up to 8-10mm (millimeter) in thickness and results in mass effect with midline shift to the left of 4mm”. A review of the Emergency Physician Record revealed clinical impressions of "acute subdural hematoma” and "dehydration." The same record stated that the resident was being transferred to a hospital in Miami for a consult with a neurosurgeon. 20. During an interview with the care plan coordinator on 8/5/04 she stated, "Most people in the falling star program don't go downstairs alone. I don't know how that happened." 21. During an interview on 8/5/04, with a resident identified by the facility as witnessing the fall, he/she stated that he/she and resident #13 were both outside on the ground floor. There were no staff members present at the time resident #13 fell from the wheelchair. A review of the Minimum Data Sets with reference dates of 2/19/04 and 5/18/04 for the resident interviewed show coding for long and short term memory as "0" indicating "memory OK." On 8/5/04, an attempt was made to telephone the nurse identified by the facility as having responded to the incident. A message was left on the answering machine but the call was not returned. 22. Resident #13 was assessed to be at risk for falls due to impairments in mobility, had a history of at least two falls (one from a wheelchair) and was seriously injured in a fall in an unsupervised area. 23. On 8/3/04, Resident #9 was observed to be one(1) of eight (8) residents sitting in the second floor dining/activity room. The resident was sitting in a wheelchair sleeping. There was no staff member in the dining/activity room until 11:00AM. 24. A review of the clinical record for Resident #9 revealed that according to the latest assessment dated 5/15/04, the resident made poor decisions requiring cues or supervision. Further review indicated that the resident was dependent on staff for transfers and test for balance, balance while standing was not attempted without physical help. Also, the assessment indicated that the resident had fallen in the past 30 days and in the past 31-180 days. A review of the nurses' notes dated 7/28/04 stated that the CNA found the resident on the floor in the dining room lying on her/his right side. The note further stated that a contusion with hematoma was forming over the right eye and up to the right cheek area. Continued review of the clinical record for resident #9 revealed that the Resident Assessment Protocol Guide (RAP) for falls initially dated 12/29/03 and last updated 5/30/04, indicated that the resident had a history of falls. The RAP further revealed that the resident had the following internal risks factors that represent an underlying health problem that can cause falls: HTN, unsteady gait, lethargic, decline in function, Alzheimers. The RAP also revealed that the resident was at risk for future falls due to Alzheimer's, lethargy, weakness and poor safety awareness. 10 25. Resident #9 had a care plan, which included limited assistance with bed mobility. Other approaches included: providing adequate time to complete tasks, assistance with mobility as needed, reinforcement of safety issues, call bell within reach, and orientation frequently to use Falling Star Program. A review of the facility’s policy, “Falling Star Program”, revealed that the program was a comprehensive practice guide designed to identify and address residents ‘actively at risk' for falls. The program description included, but was not limited to: rehab screens when indicated, monitoring medications for side~effects that can cause dizziness and falls, using wheelchair and bed alarms as indicated, frequently (no less than hourly) visual checks on residents who have been identified as fall risks, and using alarms and or restraints. 26. A review of the clinical record revealed a physical therapy progress note dated 7/29/04. The note stated that resident #9 attempted to stand from a wheelchair on 7/28/04 and fell sustaining a contusion on forehead. Resident #9 seemed to be increasingly confused. The note continued on that at this time resident was very sleepy and did not seem to be at risk for further falls but should be observed when out of bed to prevent further falls. 27. During an interview with the Director of Nurses' (DON) and the care plan coordinator on &/4/04, the DON stated that Ik from her investigation the resident fell or slid out of the wheelchair. During continued interview with the DON on 8/5/04 regarding the resident's fall on 7/28/04, she stated that a noise was heard in the dining room. The resident was found right next to her/his wheelchair. The DON further stated that when a fall occurs an unusual occurrence record is filed. The fall is also written in the 24-hour report. Falls are discussed at the morning meeting. At this time if a resident falls therapy is asked to screen the resident the next day that they are in the building. The DON stated that she informed physical therapy of resident #9's fall. The DON was informed at this time that a physical therapy screen was not seen on the chart. 28. A review of the clinical record for resident #14 revealed that the resident was initially admitted to the facility on 7/12/01 with the following diagnoses among others: CVA and fracture of neck of femur. According to the latest assessment dated 4/15/04, the resident was independent with decision-making ability. Further review of the assessment indicated that the resident required supervision with transfers, ambulating in the room and locomotion on the unit. The resident was continent of bowel and bladder. 29. A review of the nurses' notes dated 11/4/03 at 10:30PM revealed that the resident was found on the floor on his/her right side, yelling for help. According to the notes, the 12 resident's range of motion was within normal limits, but the resident was weak and his/her color was gray. A skin tear was noted on the right elbow. Ecchymotic areas were noted around the right eye and cheekbone. The notes further stated that the resident was instructed to use the call light by demonstration due to language barrier. Nurses' notes again on 11/4/03 at 11:15PM state resident was calling for help and found sitting on floor, next to wheelchair. The note continues to state usual ROM (range of motion), but very weak. Instructed by Spanish interpreter to use call light for assistance when getting out of bed. 30. A review of the nurses' notes dated 6/20/04 at 10:00 PM reveal that a Certified Nursing Assistant (CNA) found the resident lying on the floor face down with a laceration of the left cheek, skin tear to left elbow and skin (arrow pointing down) part left forearm. 31. A review of the Resident Assessment Protocol (RAP) for falls dated 4/15/04 indicated that the resident had a history of falls. Under the heading “explain the circumstances of the fall(s)" the writer wrote "slid off w/c (wheelchair) while wheeling self from activity room to outside balcony by sliding door. Fell 2x while transferring B/W (between) bed and chair. Internal risk factors identified were Procardia, Vioxx and joint pain arthritis. Common side effects of Procardia, a medication 13 used for the treatment of chest pain and hypertension, are dizziness, light-headedness, headache and weakness. Common side effects of Vioxx, a medication used for relief of signs and symptoms of osteoarthritis, are headache, fatigue and dizziness. (Reference: 24th Edition of Nursing 2004 Drug Handbook). The RAP further indicated that the resident received cardiovascular medications along with anti-anxiety/hypnotics. The RAP further revealed that the resident used an assistive device. The writer of the RAP indicated that the resident needed assistance for transfers, didn’t ask for help, and was a potential for future falls. A plan of care was written relating to the history of falls and potential for future falls, unsteady gait and need for assistance at times of transfer. 32. A review of the care plan dated 4/15/04 for potential for injury stated there was fall risk related to unsteady gait, weakness, and the resident not always asking for assistance to transfer. The goals listed were that the resident will remain free from falls and fall related injuries, resident will verbalize understanding of the need for assistance and resident will demonstrate ability to use assistive device safely and consistently by 7/14/04. The interventions listed were: keep call light, place most frequently used personal items within reach, provide verbal reminders to resident to call when needing assistance, maintain room and pathways free of clutter, and 14 ensure adequate lighting, provide night light if needed, PT/oOT evaluation as indicated, and/or every 3 months, assess need for fall interventions such as: low bed, bed or chair alarms, non- skid strips on floor, gripper, raised toilet seat, padded floor next to bed and wedge in chair and educate resident in safety awareness. A review of the clinical record indicated that the resident was not evaluated by physical therapy after the two falls on 11/4/03. Also the care plan did not address the fact that the resident required assistance to transfer nor was there evidence that the resident was educated in safety awareness. 33. During an interview with the Director of Nurses (DON) on 8/5/04, she stated that when a resident has a fall, the fall is written in the 24 hour report. Then, Falls are discussed at the morning meeting. If a resident falls, therapy is also asked to screen the resident the next day that they are in the building. 34. Based on the foregoing facts, Marathon Manor violated 483.25 (h) (2), Code of Federal Regulation as incorporated by Rule 59A-4.1288, Florida Administrative Code herein classified as a Class II violation pursuant to Section 400.23(8), Florida Statutes, which carries an assessed fine of $5,000.00. The fine is doubled due to the citing of a Class II violation during survey of June 25, 2004 and June 26, 2004. 15 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Counts I and II. 2. Assess against Marathon Manor an administrative fine of $10,000.00 for the violations cited above. 3. Assess costs related to the investigation and prosecution of this matter, if applicable. 4. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2003). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 1, Esq. i I ral Counsel naaned for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 305-470-6800 Copies furnished to: Diane Castillo Field Office Manager Agency for Health Care Administration Manchester Building 8350 NW 52 “4 Terrace Miami, Florida 33166 (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 Terry Hilker, Administrator, Marathon Manor, 320 Sombrero Beach Road, Marathon, Florida 33050; Theresa B. Cleveland, 810 Saturn Stree ~ Suite 17, Jupiter, Florida fi , 2004, 33477 on this Fh day of ates let/\Julien, q.

Docket for Case No: 04-004508