STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR porerye 4 ae HEALTH CARE ADMINISTRATION, 2 Petitioner, vs. Case Nos. 2004008866 2004008865 PALM BAY HEALTH CARE ASSOCIATES, re LLC, d/b/a THE PALMS REHABILITATION Ol . (| ly Ke / . & HEALTHCARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against PALM BAY HEALTH CARE ASSOCIATES, LLC, d/b/a THE PALMS REHABILITATION & HEALTHCARE CENTER, (hereinafter “Respondent”), pursuant to §§ 120.569, and 120.57, Fla. Stat., (2004), and alleges: NATURE OF THE ACTION This is an action to impose upon the Respondent an administrative fine in the amount of $5,000.00 and assign to the Respondent a conditional licensure status for the period commencing on August 26, 2004, and ending on November 30, 2004, based upon two (2) cited State Class II deficiencies. JURISDICTION AND VENUE SSSR REESE AVN END VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of 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, Fla. Admin. Code R. 590-4. 4. Respondent operates a 120-bed nursing home located at 5405 Babcock Street NE, Palm Bay, Florida 32905, and is licensed as a skilled nursing facility (License Number SNF130470985) . 5. Respondent was at all times material hereto a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to Fla. Admin. Code R. 59A-4.1288, incorporating by reference 42 CFR § 483.13 (b), facility residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. 8. On or about 08/23/04 through 08/26/04, the Agency conducted a recertification survey (hereinafter “08/26/04 survey”) of the Respondent’s facility (hereinafter “Facility”). 9. Based on record review and interview, the Facility failed to ensure that 1 of 23 sampled residents (Resident #15) was free from physical abuse and/or corporal punishment. 10. Record review and interview indicated that a Facility staff member who was trying to reacquire medications from Resident #15 injured that resident. 11. Record review revealed that the Resident #15 was transferred to the hospital on 04/25/04 with trauma of the left hand. 12. A resident transfer form dated 04/25/04 indicated: “additional pertinent information: patient’s hand was hurt when nurse forced [him/her] to open hand.” 13. Review of nurse’s notes dated 04/25/04 at 6:45 p.m. revealed that Resident #15 was in his/her wheelchair in the hallway holding his/her left hand, saying look what [he/she] did. Those same nurse’s notes further documented: “writer looked at pt [patient] hand and first three fingers bleeding around nail beds. Writer took pt to [his/her] nurse and began yelling [he/she] did it. [Nurse] voiced pt would not take meds [medications] nor give them back so [he/she] took them from pt. 14. Nurse’s notes dated 04/25/04 at 6:50 p.m. documented the following: “seen res. [resident] sitting in w/c [wheel chair] near the nurses station crying and holding left hand. Noted three fingers bleeding, holding cloth wiping fresh blood. Res. [resident] stated [he/she] grabbed my hand and took pills 15. Interview with Resident #15’s family member, power of attorney (POA) and another family member on 08/25/04 revealed they were called by the facility on the night of the incident to take the Resident #15 to the hospital because of bruised fingers as the result of an incident with a nurse trying to take medications from the resident’s hand by force. According to the POA, Resident #15 was taken to the hospital and X-rays were taken but the resident did not have any fractures. 16. Interview with the Facility’s risk manager (“Risk Manager”) on or about 08/26/04 indicated that the Facility’s internal investigation revealed that on 04/25/04 Resident #15 reported to the nurse on duty that another nurse hurt his/her hand and complained of pain in left hand. 17. Interview with the Risk Manager on or about 08/26/04 revealed that scratch marks and a red area were observed next to Resident #15’s middle finger cuticle. 18. Interview with the Risk Manager on or about 08/26/04 revealed that the nurse involved in this incident stated he/she was attempting to pry medicine out of Resident #15’s hand after Resident #15 refused to take them and also refused to give them back to him/her. 19. Interview with the Risk Manager on or about 08/26/04 revealed that the nurse who pried the medicine out of Resident #15's hand was immediately suspended pending investigation and was escorted out of the building. 20. Interview with the Risk Manager on or about 08/26/04 revealed that Resident #15 was taken to the emergency room and that the incident was reported to the police, Adult Protective Services, and the Agency for Health Care Administration field office at approximately 10:00 p.m. 21. Interview with the Risk Manager on or about 08/26/04 revealed that the nurse decided to resign when he/she was informed about the Facility’s decision to terminate him/her. 22. Interview with the Risk Manager on or about 08/26/04 revealed that the nurse was reported to the Board of Nursing the day after the incident. 23. Nurse’s notes dated 04/26/04 at 12:25 a.m. indicated: “resident returned with [family member], no paper work returned with resident. Resident voiced they took 3 different positions X-rays ... they were OK, nothing broken. Left hand middle finger with band aid on tip of finger covering nail.” 24. Review of the emergency room assessment dated 04/25/04 confirmed X-rays of the left hand were normal with no fractures but the clinical impression documented the resident sustained a contusion of the left hand. 25. The Agency determined that this deficient practice, which affected one resident, compromised that resident’s ability to reach or maintain 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, and, provision of services. 26. This deficient practice constitutes an isolated State Class II deficiency. 27. The Agency provided Respondent with a mandatory correction date of 09/16/04. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8) (b) and 400.102, Fla. Stat. (2004). COUNT ITI 28. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 29. Pursuant to Fla. Admin. Code R. 59A-4.1288, incorporating by reference 42 CFR § 483.25(h) (2), the Respondent must ensure that each resident receives adequate supervision and assistance devices to prevent accidents. 30. On or about 08/26/04, the Agency conducted a recertification survey of the Respondent’s Facility (“Facility”). 31. Based on observation, record review and interview, the Facility failed to ensure the provision of adequate supervision and assistive devices to prevent accidents for 4 of 23 sampled residents (Residents #1, #3, #4 & #6). 32. A review of the medical record of Resident #4 revealed a nurse's note dated 08/19/03 that indicated: “Dementia Alz type with psychotic hx. ... Hx paranoia.” 33. A nurse's note concerning Resident #4, dated 9/08/03 at 01:00 a.m., indicated: “Res is unable to make needs known, verbalizes in Spanish & mumbles.” 34. A nurse's note concerning Resident #4, dated 01/08/04, indicated: “Alert with confusion. Spanish speaking only. Staff can generally understand needs & wants by resident's actions and nodding to yes/no questions.” 35. The Minimum Data Set (hereinafter “MDS”) assessment of Resident #4, dated 08/17/04, revealed the resident to have “cognitive skills for daily decision making” at the level of “3” (severely impaired) and further indicated the presence of periods of altered perception and a variance of mental function. These findings were also reflected in Resident #4’s MDS dated 12/01/03, which was created prior to a fall that occurred on 01/19/04. 36. A physician note concerning Resident #4, dated 01/19/04, indicated: “this patient does have advanced dementia, and she/he is unable to provide a history.” 37. A review of Resident #4’s medical record revealed the following diagnoses: dementia, diabetes mellitus type II, anxiety, depression, anorexia, joint pain, organic affective syndrome, senile delusion, psychosis and insomnia. 38. The medical record of Resident #4 revealed numerous entries regarding the walking capability of this resident, usually mentioning either a steady or unsteady gait while ambulating ad lib. 39. Notes indicating Resident #4 had a steady gait or was ambulating without difficulty were entered on the following dates: 08/21/03, 09/10/03, 09/17/03, 09/18/03, 09/20/03, 10/08/03, 10/24/03, 10/25/03, 10/26/03, 10/27/03, 11/08/03, 11/14/03, 11/15/03, 12/15/03, and 01/10/04. 40. Notes indicating Resident #4 had an unsteady gait were entered on the following dates: 10/08/03, 11/12/03, 11/26/03, 12/10/03, 12/16/03, 01/08/04, 01/11/04, 01/12/04, 01/16/04, 01/17/04, and 01/18/04. 41. A note indicating Resident #4 experienced a near fall without injury was entered on 09/17/03. 42. A note indicating Resident #4 experienced a fall not resulting in an injury was entered on 10/23/04. 43. Notes indicating Resident #4 experienced a fall resulting in an injury were entered on 10/24/03, 11/12/03, 12/14/03, 01/08/04, 01/11/04, and 01/19/04. 44. A review of Resident #4’s medical record revealed the initiation of a care plan to prevent falls on 08/19/03. It was implemented due to “Dx dementia & poor safety awareness.” The approaches to be implemented as of 8/19/03 were as follows: “(1) Attempt to redirect as necessary. (2) Distant supervision as needed. (3) Assure adequate footwear when OOB. (4) Ongoing monitoring for s/s fatigue, encourage naps/rest prn. (5) Attempt to redirect to organized activities, as indicated & as available.” 45. A nurse’s note dated 09/17/03 contained the following entry: “Res was trying to go around activity asst. lost balance and fell backwards. SW caught res before [he/she] hit the floor.” No injury was noted with this near-fall. 46. A nurse’s note dated 09/18/03 at 9:05 a.m. indicated the following: “Falls action committee met day I. PT/OT {physical therapy/occupational therapy] notified request to screen, Not considered fall. Staff prevented fall.” Review of the care plan revealed the addition of the following under the “approaches” column: “9-18-03 PT/OT notified. Psych f/u.” 47. Physician orders for 10/09/03 indicated the following: “Bed/chair alarm ~ check for placement and function Q (every) shift.” 48. A nurse’s note dated 10/23/03 at 9:30 p.m. indicated the following: “res found sitting on floor @ bedside, unable to ascertain what happened d/t res speaking only Spanish @ this time. No s/s bruising/injury on initial exam.” 49. A nurse's note dated 10/24/03 at 09:25 a.m. indicated the following: “falls action committee met @ this time. PT to screen.” 50. A care plan entry on 10/24/03 indicated the following: “observed sitting on floor 10/23/03.” The approach associated with this entry was: “PT to screen.” Sl. A nurse’s note dated 10/24/03 at 9:00 p.m. indicated the following: “Nurse called to unit by CNA who reported that resident was found on floor. Resident on floor when nurse enter unit. Res c/o R hip pain...” After sending the Resident #4 to the hospital emergency room, the following entry was made on 10/25/03 at 03:00 a.m.: “Resident returned via stretcher to room ... Dx contusion (R) hip.” Consequently, this was Resident #4's first fall with injury. 52. A nurse’s note dated 10/27/03 at 09:05 a.m. contained the following entry: “Falls action committee met at this time Day 1. PT to evaluate.” 53. Consultation of Resident #4’s care plan revealed the follcwing approaches pertaining to the 10/24/03 fall: “(10/24/03) ER eval. (10/27/03) PT eval and screen. (10/28/03) PT caseload, amb balance, strengthening.” Aside from these approaches that were designed to treat Resident #4 and improve her/his overall condition over a period of time, no approaches were added to address how the Resident #4 might be better monitored and supervised while on the unit in order to prevent the occurrence of future falls. 54. An additional nurse’s note pertaining to Resident #4’s 10/24/03 fall was made on 10/28/03 at 09:05 a.m. It stated: “Pails action committee met @ this time. Day II. PT caseload. PT to work with balance & strengthening.” 55. An additional nurse’s note pertaining to Resident #4’s 10/24/03 fall was made on 10/29/03 at 09:10 a.m. It stated: “Falls action committee met Day III. PT caseload and OT”. 56. A nurse’s note dated 11/12/03 at 09:30 a.m. indicated the following: “Res was standing in room lost balance and fell to floor landing on buttocks small abrasion note to (R) elbow 1] ROM good, no s/s of pain or discomfort noted ...” Another note “ on the same day at 9:00 p.m. indicated the following: ..small bruise noted to left (upper) buttock area...” This was Resident #4’s second fall with injury. 57. Review of Resident #4’s care plan dated 11/12/03 revealed the addition of the following approaches: “PT screen. Wash area (R) elbow soap with H20 LOTA & monitor for s/s infection.” The mention of physical therapy was a repeat of a previously stated treatment approach and the washing and monitoring of the elbow was also treatment oriented. None of these approaches addressed how Resident #14 might be better monitored or supervised while on the unit in order to prevent the occurrence of future falls. 58. A nurse’s note dated 11/13/03 at 09:10 a.m. indicated the following: “Falls action committee met this a.m. Day I. PT to screen.” 59. An additional nurse's note dated 11/14/03 indicated the following: “Falls action committee met Day II. PT stated no functional decline. PT educated staff on environmental modification.” 60. An additional approach on Resident #4’s care plan made on 11/14/03 indicated: “PT educated staff concerning environmental modification.” 12 61. Interview with the Physical Therapist on 08/26/04 at 4:30 p.m. revealed that she could not produce documentation that specified the components of “environmental modification.” 62. Neither the care plan nor the nurse’s notes specified what constituted “environmental modification” in order to guide Facility staff in the care of Resident #4. 63. A nurse’s note dated 11/17/03 at 09:30 a.m. contained the following entry: “falls action committee met this a.m. Day III. Screened by PT. PT stated no functional decline. Hip Saver order obtained.” This was the first approach after two falls with injury that specifically addressed how a future fall with injury might be averted while on the nursing unit. However, since this device had to be ordered, it was not available for immediate utilization. Furthermore, it was never entered onto the care plan for reference by nursing staff in the care of Resident #4. 64. A nurse’s note dated 12/14/03 at 11:00 p.m. indicated the following: “Found res in sitting position up against wall next to bed. Noted abraised [sic] area of mid-back.” This was Resident #4’s third fall with injury. 65. A nurse's note dated 12/15/03 at 09:15 a.m. indicated the following: “Day I of falls action committee. PT to screen. Nursing to apply hip savers for protection.” The mention of physical therapy was a repeat of a previously stated treatment 13 approach. The mention of the hip savers is also a repeat of an action mentioned in 11/17/03 nurse’s notes nearly one month prior and had yet to be implemented at the time of this entry, as twenty-seven (27) days had past since the hip savers had been ordered but had not yet arrived at the facility. 66. The care plan approach dated 12/15/03 indicated the following: “PT to screen. Nursing to apply hip savers.” 67. A nurse’s note dated 12/16/03 indicated the following: “Day II of falls action committee. No functional decline. Hip savers on order.” 68. A therapy communication to nursing dated 12/16/04 mentioned hip savers and a bed alarm. 69. A nurse’s note dated 12/17/03 indicated the following: “Falls action committee Day III. Await hip savers. No functional decline. Bed alarm for placement QS.” This last note mentioned the first approach, use of the chair/bed alarm, after three falls with injury that the nursing staff could have utilized in preventing future falls of Resident #4 while on the unit. However, this approach was never entered into the care plan. 70. Documentation was produced which indicated that the alarm was being utilized in December 2003 and January 2004. However, no documentation of the performance of this order was 14 discovered for October or November of 2003, despite a request for such documentation to the unit manager on 08/23/04. 71. Resident #4’s care plan contained a brief note dated 12/18/03 that indicated the following: “Reviewed 12/18/03.” 72. A nurse’s note dated 01/08/04 at 04:00 a.m. contained the totlowing entry: “Ambulation supervised at all times.” 73. A nurse’s note dated 01/08/04 at 7:15 p.m. contained the tollowing entry: “Resident found on floor in room ...on (L) sice with blood coming from mouth.” 74. A nurse’s note dated 1/08/04 at 10:40 p.m. contained the foilowing entry: “Resident returned from ER via ambulance. Left side ... swollen.” This was the Resident #4's fourth fall with injury. 75. A nurse’s note dated 01/09/03 at 06:30 a.m. indicated three sutures had been placed on Resident #4’s upper lip. 76. A nurse’s note dated 01/09/04 at 09:20 a.m. contained the following entry: “Falls action committee Day I. To do CBC and chemistry. PT to screen for ambulation and balance.” This was another referral to physical therapy for treatment. Although the lab work could conceivably shed light on the reason Resident #4 had been falling, neither the CBC/chemistry nor the physical therapy would be of immediate benefit in preventing Resident #4 from falling while on the nursing unit. 15 77. A nurse’s note dated 01/11/04 at 10:00 p.m. contained the following entry: “Found resident kneeling on floor next to her/his bed, holding self up with rt arm on bed. Acquired sm bruise on rt. Knee.” This was Resident #4’s fifth fall with injury. 78. A nurse’s note dated 1/12/04 at 09:30 a.m. contained the following entry: “Falls action committee day II. To do stat FBS (fasting blood sugar) if found on the floor. Orthostats X 3.” Although this action could conceivably shed light on the reason the Resident #4 had been falling, it would be of immediate benefit in preventing Resident #4 from falling while on the nursing unit. Furthermore, it could not be implemented unless Resident #4 had another fall, indicative of its lack of preventive capabilities. 79. Consultation of Resident #4’s care plan revealed an entry of 01/11/04 that referred to that resident’s 01/11/04 fall, but no new approaches were entered. Even the directive mentioned in the nursing notes on 01/11/04 was not mentioned. There was no evidence of a reconsideration of prior approaches. 80. A nurse’s note dated 01/14/04 contained the following entry: “Continue to discuss with falls action committee due to frequent falls. PT working with resident.” 16 81. A nurse's note dated 01/12/04 at 2:00 p.m. contained the following entry: “... res monitored closely while ambulating.” 82. A nurse’s note dated 01/18/04 at 7:00 a.m. contained the following entry: “Awake early. Restless. Close supervision and hand held assist with ambulation (due to) unsteady gait. Leaning backwards.” 83. A nurse’s note dated 01/18/04 at 1:00 p.m. contained the following entry: “Awake, alert with confusion. 0OOB amb with supervision, slow unsteady gait.” 84. A nurse’s note dated 01/19/04 at 08:04 a.m. indicated the following: “..res was standing still lost balance fell hit head on wall and fell to floor landing face first. No open areas noted attempts to turn res around and sit her/him up res c/o pain (R) leg layed [sic] res back down; 911 called; hip savers on...” 85. A physician's note from the hospital dated 01/19/04 indicated the following: “..\he/she was found to have a left intertrochanteric hip fracture.” This was Resident #4’s sixth fall with injury. 86. A nurse's note dated 01/24/04 at 12:45 p.m., after Resident #4 had returned from the hospital, indicated the following: “Received res ... 16 sutures (L) hip post fx ... res unable to ambulate due to post hip fx...” 17 87. Although Resident #4 was restricted to the wheel chair upon return from the hospital, the care plan that was instituted on 02/04/04 upon return included approaches that would have been suitable prior to the fall of 01/19/04. Such approaches included: “(1) Monitor for signs of increased pain ... (2) Monitor for proper fitting/nonskid shoes and slippers, proper fitting clothing; (3) Observe for side effects of medication - sedation, ataxia, weakness, dizziness, vertigo, dehydration, confusion; (3) Maintain in generally supervised area when out of bed; (4) Maintain personal items in reach; (5) Monitor for signs of restlessness, agitation, anxiety and intervene; (6) Psych review meds; (7) Concave/scoop mattress.” None of these approaches had been incorporated into the care plan prior to the fall of 01/19/04. 88. A review of the approaches utilized prior to the fall of 01/19/04 indicated that there was a strong reliance on physical/occupational therapy. Interview with the Physical Therapist on 08/26/04 at 4:10 p.m. revealed that a “Functional Maintenance Program” was instituted with respect to Resident #4 and that this would have resulted in the issuance of directives to nursing regarding care for that resident. The earliest mention of a “Functional Maintenance Program” was found in the OT weekly notes, dated 10/30/03. When asked to produce such directives from OT or PT from the medical record, the Physical 18 Therapist could only produce one therapy document that gave a specific recommendation. Dated 12/16/03, it recommended a hip saver and bed alarm and, as stated above, the bed/chair alarm had already been mandated by physician order on 10/09/03. 89. The MDS dated 12/01/03, prepared prior to the fall of 01/19/04, revealed the ability to walk in the room or walk in the corridor at “1 - 0,” meaning that it was with supervision without the need of physical help by staff. Locomotion on or off the unit was graded at “4 - 2,” meaning that it was with supervision without the need of physical help by staff. The MDSs of 02/03/04, created upon return from the hospital and 08/17/04 revealed the ability to walk in the room or walk in the corridor at “8 - 8,” meaning that it did not occur. Locomotion on or off the unit was graded at “4 - 2,” meaning that it involved total dependence and one-person physical assist. 90. The falls Care Plan dated 06/18/04 indicated that Resident #4 should use of a wheelchair when out of bed. During the survey, Resident #4 was not observed ambulating without assistance, as prior to the fall of 01/19/04. These entries indicated a decline in the resident's ambulatory abilities. 91. Resident #4 experienced a total of six falls with injury, the last one resulting in a hip fracture. During the time period from the occurrence of the first fall with injury, 10/24/03, to the fall of 1/19/04, only one approach that was 19 suitable to inhibit falls immediately (a bed/chair alarm on the unit} was incorporated into the plan of care although not formally stated on the falls Care Plan and already ordered via a physician order of 10/09/03. There was no documentation confirming compliance with this order in October or November of 2003. The hip savers took several weeks to arrive and were, therefore, not a suitable approach for immediate implementation. Various diagnostic and therapeutic approaches were added, as stated above primarily in nurse’s notes, but only physical therapy was formally entered in the Care Plan. None of these appreaches were suitable to immediately inhibit the opportunities for falls with injury. 92. One approach required the occurrence of another fall before it could be implemented, the FBS. Despite the apparent ineffectiveness of therapy to prevent falls on the unit, demonstrated by a series of falls with injury in the general time frame when therapy took place, a strong and continued reliance was placed upon this approach to the exclusion of other possibilities. 93. In cases where no new approaches were added to the Care Plan after a fall with injury, there was no evidence in the record that prior approaches had been reviewed as to their suitability. 20 94. During this entire time period, only one recommendation was communicated by therapy to nursing. 95. It was only after the Resident #4 returned to the facility after the last fall on 01/19/04 that numerous creative approaches to prevent falls were incorporated into the Care Plan. Despite various mentions of close observation of the resident in the time period shortly before the fall, Resident #4 experienced six falls, the last resulting in a fracture of the left hip. 96. Review of Resident #6's clinical record revealed initial admission date of 5/12/04 with diagnoses including malnutrition, difficulty walking, muscle and general wasting. 97. Review of Resident #6’s admission MDS, dated 06/03/04, revealed that that resident had modified independence in decision making. 98. Review of Resident #6’s MDSs dated 06/25/04 and 07/16/04 indicated that resident engaged in independent decision making. 99. Review of the 06/03/04, 06/25/04 and 07/16/04 MDSs for Resident #6 revealed that that resident was non-ambulatory and required extensive assistance, with one-staff assistance indicated for transfers and toileting. 100. Review of a nurse’s note dated 05/17/04 at 10:10 a.m. revealed Resident #6 had fallen to the floor, resulting in 21 swel-ing of the left wrist. An x-ray was taken with negative results. A physician’s telephone order (TO) was obtained on 05/17/04 for a bed/chair alarm, check function and placement every shift. 101. Review of the 05/12/04, 5/25/04 and 06/18/04 fall risk data collection sheets scored the resident at 14, 16 and 9, respectively. 102. Further review of the fall risk data collection sheet did not indicate which score would place a resident at high risk. 103. Interview with the nurse on 08/24/04 at approximately 1:30 p.m. confirmed no scoring tool was found on the sheet to indicate what score placed the resident at high risk but stated the higher the score, the greater the risk for falls. 104. Review of the 08/04 physician's order sheet (POS) indicated a bed/chair alarm, check function and placement every shift for Resident #6. 105. Review of the 08/16/04 falls care plan and certified nursing assistants (CNAs) 07/01/04 falls care plan indicated the use of a bed/chair alarm, check placement and function every shift for Resident #6. 106. Resident #6 was observed in the wheelchair on 08/23/04 at 3:45 p.m., on 08/24/04 at 11:51 a.m. and 12:52 p.m., and on 08/25/04 at 10:45 a.m. with no chair alarm. 22 107. Review of the 08/04 treatment administration sheet (TAR) identified the bed/chair alarms, check function and placement every shift and revealed no evening nurse’s signature on 08/23/04 to indicate if the alarms were in place or not. 108. Day shift nurses signatures on 08/24/04 and 08/25/04 indicated alarms were in place. 109. In an interview of a CNA conducted on 08/25/04 at approximately 10:49 a.m., while that CNA was providing care to the Resident #6, revealed that that resident did not have alarms. 110. Interview with the nurse on 08/25/04 at 10:49 a.m. stated the alarms were not being used during the day but on the evening and night shifts. She indicated Resident #6 was being allowed more freedom in preparation of discharge to home in a few days. She further indicated Resident #6 used the call light for assistance and was unable to recall how long the alarms were not used on the day shift. 111. Interview with the unit nurse manager on 08/25/04 at 11:00 a.m. confirmed that Resident #6 had no bed or wheelchair alarms. She stated the alarms should not have been discontinued until the fall risk interdisciplinary team met to discuss if it was safe to discontinue the alarms. 112. Record review reveled that Resident #1 has had several falls, some with injury, in the Facility. 23 113. Review of Resident #1’s plan of care indicated that that resident was to wear a soft helmet while out of bed. 114. On 8/23/04 at 2:30 p.m., Resident #1 was observed in bed. Several minutes later at approximately 2:43 p.m., Resident #1 was escorted out of his/her room by a CNA, who indicated that the resident was being taken to an activity. Resident #1 sat in a chair during the activity. During this observation Resident #1 was not wearing the soft helmet. 115. On 08/24/04 at approximately 9:58 a.m., one CNA was observed wheeling sampled Resident #3 into his/her room in the wheel chair. 116. Resident #3 was placed near the bed in his/her room and the CNA proceeded to get a Hoyer lifter from the hallway, went back into the room and closed the door. When the CNA came out of Resident #3’s room at approximately 10:10 a.m., the resident was observed in bed. There were no other staff members observed in Resident #3’s room at that time. 117. Interview with the CNA on 8/24/04 at approximately 10:11 a.m. revealed the CNA had transferred Resident #3 from the wheel chair to the bed by him/herself using the Hoyer lift. 118. A nurse who was in the hallway in front of Resident #3's room and witnessed the interview with the CNA indicated to the CNA that Resident #3 required two persons assist for transfers. 24 119. Review of the resident's care plan for functioning and mobility dated 4/15/04 and reviewed on 7/15/04 documented the following approach: “TRANSFERS: DEPENDENT; MECHANICAL LIFT (HOYER) 2 PERSON ASSIST.” 120. The Agency determined that these deficient practices presented immediate threats to the residents and situations in which immediate corrective action was necessary because Respondent's non-compliance was likely to cause serious injury, harm, impairment, or death to a resident receiving care at Respendent’s facility. 121. The Agency determined that this deficient practice, which affected a very limited number of residents, compromises those residents’ ability to maintain or reach their highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, an provision of services. 122. The Agency determined that these deficient practices constitute an isolated State Class II deficiency. 123. The Agency provided Respondent with a mandatory correction date of 09/16/04. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8) (b) and 400.102, Fla. Stat. (2004). 25 COUNT III 124. The Agency re-alleges and incorporates paragraphs one (1) through five (5), seven (7) through twenty-seven (27), and twenty-eight (28) through one hundred twenty-three (123) as if fully set forth herein. 125. Based upon Respondent’s two (2) cited state class II deficiencies, it was not in substantial compliance, at the time of the survey, with criteria established under Part II of Florida Statutes, Chapter 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7) (b), Fla. Stat. (2004). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(7) commencing on 04/08/04 and ending on 07/19/04. Respectfully submitted this /6™ day of November, 2004. tan T.. Mutligan Fla. Bar. No. 0676543 Agency for Health Care Admin. 525 Mirror Lake Drive, 330L St. Petersburg, FL 33701 727.552.1439 (office) 727.552.1440 (fax) 26 DISPLAY OF LICENSE Pursuant to § 400.23(7) (e), Fla. Stat. (2003), Respondent shall post the most current 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. 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 Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922- 5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by certified mail, return receipt no: 7003 1010 0003 0298 4640 on November 76 , 2004 to Todd Werthman, Administrator, The Palms Rehabilitation & Healthcare Center, 5405 Babcock Street, NE, Palm Bay, Florida 32905 and U.S. Mail to CT Corporation System, Registered Agent for The Palms Rehabilitation & Healthcare Center, 1200 South Pine Island Rd., Plantation, Florida, 33324. Brian Z A fle Copies furnished to: Todd Werthman Administrator The Palms Rehab. & Healthcare Center 5405 Babcock Street NE Palm Bay, FL 32905 (U.S. Certified Mail) 27 CT Corporation System Registered Agent The Palms Rehab. & Healthcare Center 1200 South Pine Island Rd. Plantation, FL 33324 (U.S. Mail) Brian T. Mulligan Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, Suite 330L St. Petersburg, FL 33701 28 PAYMENT FORM 204 CEC 27 P 2 33 Agency for Health Care Administration [eta Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. in the amount of $ , Which represents payment of the Administrative Fine imposed by AHCA. Titusville Rehab. Nursing Center 2004009584 2004009583 Facility Name AHCA No.

Docket for Case No: 04-004638