Ay STATE OF FLORIDA / AGENCY FOR HEALTH CARE ADMINISTRATION 4oilvis MS EM i 18 AGENCY FOR HEALTH CARE ARNE Pr ADMINISTRATION, Gs Petitioner, AHCA No.: 2004008883 Return Receipt Requested: v. 7003 1680 0006 9825 7734 7003 1680 0006 9825 7741 BAY OAKS HOME FOR THE AGED d/b/a BAY OAKS HOME FOR THE AGED, INC. Respondent. f Os-o ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Bay Oaks Home for the Aged d/b/a Bay Oaks Home for the Aged, Inc. (hereinafter “Bay Oaks Home for the Aged, Inc.”), pursuant to Chapter 400, Part III, and Section 120.60, Florida Statutes, (2003), and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine of $1,500.00 [$1,000.00 administrative fine + $500.00 survey fee] pursuant to Sections 400.414 and 400.419, Florida Statutes for the protection of the public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57 Florida Statutes, Chapter 28-106, Florida Administrative Code. 2. Venue lies in Miami-Dade County pursuant to Section 120.57 Florida Statutes, Rule 28-106.207, Florida Administrative Code. PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 400, Part III, Florida Statutes (2003) and Chapter 58A-5 Florida Administrative Code. 5. Bay Oaks Home for the Aged, Inc. operates a 37-bed assisted living facility located at 435 N. E. 34 Street, Miami, Florida 33137. Bay Oaks Home for the Aged, Inc. is licensed as an assisted living facility under license number 5168. Bay Oaks Home for the Aged, Inc. was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I BAY OAKS HOME FOR THE AGED, INC. FAILED TO ENSURE THAT ADEQUATE SUPERVISION WAS PROVIDED TO A RESIDENT BASED ON HIS/HER SPECIFIC IDENTIFIED LEVEL OF NEED. RULE 58A-5.0182(1)(c), FLORIDA ADMINISTRATIVE CODE (RESIDENT CARE STANDARDS) CLASS II VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Bay Oaks Home for the Aged, Inc. was cited with one (1) Class II deficiency due to a complaint investigation conducted on August 11, 2004. 8. A complaint investigation was conducted on August 11, 2004. Based on observation, interview and record review, it was determined that the facility failed to ensure that adequate supervision was provided to a resident based on his/her specific identified level of need, resulting in actual harm to the resident (Resident #4). The findings include the following: 9. Resident record review conducted 08/02/2004 between approximately 1:15 p.m. and 3:30 p.m. revealed that Resident #4 was admitted to the facility on 12/31/02 with diagnoses of Severe Parkinson's disease, Osteoporosis, Dementia, and Depression. A review of Resident #4's health assessment dated 12/18/2002, revealed that the resident's doctor indicated that the ‘patient needs supervision", and "avoidance of falls" was listed under special precautions. An entry in the resident record dated 03/29/2003 described an incident in which the resident was confused about his/her room, insistine that he/she had not slept in the room, and that someone else slept in the room. According to the resident record entry dated 07/10/03, the resident was "increasingly confused" with "flight of ideas" and “Nambulatory with cane or walker with supervision". An entry dated 02/14/2004 revealed that the resident was "trying to leave", "going shopping" but due to staff intervention, was prevented from leaving the premises. -0. Interview with the involved staff member (CNA #1) on 08/02/2004 at 4:05 p.m. revealed that the resident had tried "a couple of times to go out of the gate" but was re-directed by facility staff. 11. An interview with the Administrator on 08/02/2004 between 12:05 and 12:30 p.m., revealed that the resident had been dining later than other residents as a result of a decline in function. According to the Administrator, the resident was usually brought to the dining room by any of the CNAs once the first set of residents were finished eating at approximately 2 p.m. On 06/16/2004, the junch meal began and ended later than usual. During the 08/02/2004 interview with CNA #1, it was learned that on June 16, the resident was last ebserved lying down in his/her room at 11:30 a.m. prior to being found by a passer-by outside of the building, face down in the dirt at 2 p.m., representing a two and one-half (2.5) hour interval in 4 which the at-risk resident's whereabouts were unaccounted for. Fire rescue was called, and Resident #4 was transferred to an area hospital. A review of hospital records on 08/11/2004 revealed that the resident was assessed in the Emergency Department to have a temperature of 107 degrees, "possibly secondary to hyperthermia" and that "no evidence of any infection was found". On 08/02/2004 at 11:55 a.m., observation was made of the fire exit on the east side of the building through which the resident exited, and of the area adjacent to the stairs where the resident was later found. The area in which the resident was found was unable to be visualized by staff, and the door that led to this area had no alarm in place at the time of the resident's egress from the building. 12. Based on the foregoing facts, Bay Oaks Home for the Aged, Inc. violated Rule 58A-5.0182(1) (c), Florida Administrative Code, herein classified as a Class II violation, which warrants an assessed fine of $1,000.00. SURVEY FEE Pursuant to Section 400.419(10), Florida statutes, AHCA may assess a survey fee of $500.00 to cover the cost of monitoring visits. A survey fee of $500.00 has been assessed in this case. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: lL. Enter a judgment in favor of the Agency for Health Care Administration against Bay Oaks Home for the Aged, Inc. on Count I. 2. Assess an administrative fine of $1,000.09 against Bay Oaks Home for the Aged, Inc. on Count I for the violation cited above. 3. Assess a survey fee of $500.00 against Bay Oaks Home for the Aged, Inc. pursuant to Section 400.419(10), Florida Statutes. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this 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 acticn are set out in the attached Election of Rights and explained in the attached Explanation of Rights. Ali 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 THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. i one Agency for Health Caze 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 8355 N.W. 53 Street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) Assisted Living Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive 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 Kathryn Kassner, Administrator, Bay Oaks Home for the Aged, Inc., 435 N.E. 34 Street, Miami, Florida 33137; Mazelle Florio, Registered Agent, 435 N.E, 34 Street, Miami, Florida 33137 on this ¥th day of bither , 2004. wv Margar¢t olulien

Docket for Case No: 05-000117