3/2285 18:56 PRPST214649 SHCA GENERAL CDUNSEL STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA No. 2004007585 RULEME CENTER, LLC d/b/a RULEME CENTER, OS - 0 Z \ Vv Respondent. J ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION ("AHCA" or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against RULEME CENTER, LLC d/b/a RULEME 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 administrative fines totaling TWENTY THOUSAND DOLLARS ($20,000) upon Respondent, pursuant to Section 400.23(8)(b), Florida Statutes, and a six-month survey cycle fee of SIX THOUSAND DOLLARS ($6,000) upon Respondent, pursuant to Section 400.19, Florida Statutes. JURISDICTION AND VENUE 2. The Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes. Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 1 of 12 Dis 3Ly E25 18:55 7275521440 SHOR GENERAL CDUNSE Pace 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 Il, Florida Statutes, and; Chapter 59A~4 Fla. Admin. Code, respectively. 5. Respondent, RULEME CENTER, LLC, owns and operates a skilled nursing facility in the state of Florida. The facility, RULEME CENTER (‘Facility’), is a 138-bed nursing hame located at 2810 Ruleme Street, Eustis, Florida 32726. Respondent is licensed as a skilled nursing facility, having been issued license #SNF11450961, effective October 10, 2000. Respondent was at all times material hereto, a licensed facility under the licensing authority of AHCA, and was required to comply with all applicable regulations, statutes and rules. COUNT CLASS | ISOLATED VIOLATION FOR FAILURE TO ENSURE THAT SERVICES PROVIDED OR ARRANGED BY THE FACILITY MET PROFESSIONAL STANDARDS OF QUALITY 42 CFR 483.20(k)(3)(i) Section 400.23(8)(a), Florida Statutes Rule 59A-4.1288, Fla. Admin. Code 6. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 7. The regulatory provisions of the Code of Federal Regulations that are pertinent to this alleged violation, read as follows: Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 2 of 12 FEISSEL4d40 6HCA GENERAL COUNSEL 42 CFR 483.20 Resident assessment. The facility must conduct initially and periodically a comprehensive, accurate. standardized, reproducible assessment of each resident's functional capacity. aoe (k) Comprehensive care plans. nee (3) The services provided or arranged by the facility must -- (i) Meet professional standards of quality. 8. AHCA surveyors conducted an annual survey of Respondent's facility on or about July 29, 2004, which revealed the following: The facility failed to notify the physician of a significant change in condition which created a serious and immediate threat to the health of 1 (#14) of 42 sampled residents who was in an emergency situation with a compromised airway, decline in blood pressure and abnormal vital signs reflective of respiratory distress and who, approximately 3 hours and 50 minutes tater was found deceased in his/her bed. Specific findings were: a). Record review for resident #14 revealed a Nursing Note for 7/26/04 at 11:30 PM documented “Patient vomited large amount of emesis, contained food particles", and was signed by LPN #4. The next nurses note entry was dated 7/27/04 at 12 AM and documented "Patient moaning in bed, raspy, gurgling breath sounds. Patient cannot clear throat with coughing. States she doesn't feel well but can't pin point what it is that doesn't feel well. Will continue to monitor", and was signed by LPN #4. The next nursing note was dated 7/27/04 at 3:50 AM and documented "CNA (certified nursing assistant) reported (resident #14) didn’t seem to (be) breathing, when | checked for breath sounds there were none, no heart sounds/pulse. MD and family notified’, and was signed by LPN #4. b). Interview with LPN #5 on 7/29/04 at 3:58 PM revealed that between 11:45 PM and 12:00 midnight she entered the room with LPN #4 and looked at the resident. LPN #5 stated the resident was lying in bed with the head of the bed elevated at a 45 degree angle and {ooked pale and his/her “lips were a little blue". She stated the resident "didn't look too good”. LPN#5 also stated she never saw or overheard LPN #4 speaking to the physician on the phone c). Review of the "Vital Sign Record Sheet" for resident #14 revealed one entry dated 7/27/04. Blood Pressure was documented as 88 Systolic and 46 Diastolic, Temperature of 96.1 degrees, pulse of 124 beats per minute and respiration of 30 breaths per minute. d). Review of the Physician Notification Policy dated 11/01/03 revealed the Policy is "Physicians should be kept informed of significant changes in status of the customer (resident). The Process includes: 4. Nurse is to contact the attending physician ta report nursing assessment/observations related to a change in condition. 2. Physician Notification Nurse's Note should be completed prior to contact of physician. 3. Document reason for Physician Notification. 4, Nurse should obtain any new orders from the physician 5. Nurse should transcribe orders to the Medication Administration Record or Treatment Administration Record. 6. Update care plan with any new problem or any change in approaches related toa change in condition. Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 3 of 12 BLS21L/2805 18:56 7275521448 BHOA GENERAL COUNSEL Pace Notification parameters included “ashen or dusky appearance, cyanosis, pulse over 120 beats per minute and respirations over 30 breaths per minute". e). Interview with the facility's Medical Director, (who was resident #14's attending physician), on 7/29/04 at 9:55 AM failed to reveal that he was notified at the time of the resident's significant change in condition, that was documented in the nurses‘ note of 7/27/04 al 12:00 AM. 9. Respondent's failure to ensure that services provided or arranged by the facility met professional standards of quality is a violation of Rule S9A- 4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.20(k)(3)(i). 410. AHCA classified the nature and scope of this violation as a class | “isolated” violation. Pursuant to Section 400.23(8)(a), this classification constitutes grounds for the imposition of an administrative fine of TEN THOUSAND DOLLARS ($10,000). A class | violation is defined as one that “the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility.” COUNT II CLASS | ISOLATED VIOLATION FOR FAILURE TO PROVIDE NECESSARY CARE AND SERVICES 42 CFR 483.25 Section 400.23(8)(a), Florida Statutes Rule 59A4-4.1288, Fla. Admin. Code 11. AHCA re-alleges and incorporates by reference paragraphs (1) through (5) above as if fully set forth herein. 12. The regulatory provisions of the Code of Federal Regulations that are pertinent to this alleged violation, read as follows: Administrative Complaint 2004007585 Certiied Number 7106 4575 1294 2049 8460 Page 4 of 12 256 PRPOUSZ1ASE SHCA GENERAL COUNSEL PACE 42 CFR 483.25. 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 13. | AHCA surveyors conducted an annual survey of Respondent's facility on or about July 29, 2004, which revealed the following: The facility failed to provide care and services which created a serious and immediate threat to the health of 1 (#14) of 42 sampled residents who was in an emergency situation with a compromised airway, decline in blood pressure and abnormal vital signs reflective of respiratory distress, who approximately 3 hours and 50 minutes later was found deceased in his/her bed. Specific findings were: 1. Observation on 7/26/04 at approximately 2:45 PM revealed resident #14 lying in bed asleep, with a pillow under his/her head. Interview at 7/26/04 at 2:45 PM with the licensed practical nurse (LPN #3) assigned to the resident revealed he/she was a Diabetic with regular Accuchecks for blood sugar monitoring, but was non-compliant with medication intake. The nurse stated he/she requires extra time with the administration of medication and sometimes the nurse needs to keep trying with the offer of the medication. Further interview revealed the resident can independently locomote or maneuver his/her wheelchair around the facility. 2. Record review for resident #14 revealed the resident was admitted on 11/23/03 with diagnoses that included Diabetes Mellitus with Insulin coverage, Hypertension, History of Colon Cancer and Gastric Resection, GERD (Gastric Esophageal Reflux Disease). The "POS" or Physician Order Sheet for July 2004 Documented under the Plan of Care the resident's code status as "Do Not Resuscitate” and the resident's "Prognosis" and “Rehab Potential” was documented as "Good". The order confirmed the resident received Accuchecks three times per day and Novolin Regular insulin was dispensed on a sliding scale according to the resident's blood sugar. The resident's medications included an order for Glucagon injections to be used "as needed" for Hypoglycemia (low blood sugar) and injections of Phenergan, 25 mg to be given "as needed" every 6 hours for Nausea and Vomiting. The resident was prescribed Three medications for the diagnosis of GERD; Metoclopramide 5 mg before meals and at bedtime, Protonix 20 mg 1 per day and Sucralfate 1 gm 1/2 hour before meals and at bedtime. 3. Observation on 7/27/04 at 8:47 AM revealed resident #14's bed was stripped of bed linens and the resident was not in the room. Inquiry with the 7:00 AM to 3:00 PM shift nurse on 7/27/4 at 8:47 AM revealed the resident had expired at 3:58 AM. The nurse (#3) stated the resident had a vomiting episode and that the resident's Doctor was called. 4. Record review revealed a Nursing Note for 7/26/04 at 11:30 PM documented "Patient vomited large amount of emesis, contained food particles", and was signed by LPN #4. The next nurses note entry was dated 7/27/04 at 12 AM and documented “Patient moaning in bed, raspy, gurgling breath sounds. Patient cannot clear throat with coughing. States she doesn't fee! well but can't pin point what it is that doesn't feel well. Will continue to monitor”, and was signed by LPN #4. The next nursing note was dated 7/27/04 at 3:50 AM and documented "CNA (certified nursing assistant) reported (resident #14) didn't seer to (be) breathing, when | checked for breath sounds there were none, no heart sounds/pulse. MD and family notified", and was signed by LPN #4. Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 5 of 12 DELS AHCA GENERAL COUNSEL Bae 5. Record review revealed a "Vital Sign Record Sheet" with one entry dated 7/27/04. Blood Pressure was documented as 88 Systolic and 46 Diastolic, Temperature of 96.1 degrees, pulse of 124 beats per minute and respiration of 30 breaths per minute, Review of the Physician Notification Policy dated 11/01/03 revealed the notification parameters included “ashen or dusky appearance, cyanosis, pulse over 120 beats per minute and respirations over 30 breaths per minute. 6. Interview with CNA #1 on 7/29/04 at 3:25 AM revealed she as the CNA assigned to resident #14 for the 10:00 PM to 6:00 AM shift and was familiar with the events surrounding the time leading up to the resident expiring. CNA #1 stated that prior to transferring care responsibilities of residents fram one CNA to another, each resident is discussed and visually checked. This is referred to as “exchange rounds”. At approximately 9:45 PM CNA #1 received information that resident #14 had an episode of vorniting and had been cleaned up. CNA #1 confirmed the resident was dressed in clean garments at this time. At the end of exchange rounds CNA #1 checked on resident #14 and found that he/she had vomited again, in amount that covered his/her upper torso with what looked like food particles. The CNA stated she notified LPN #4, who instructed her to clean up the resident and let her know if it happened again. CNA #1 stated that during the time when she cleaned up resident #14, she raised the head of the bed to a 45 degree angle. Inquiry related to the elevation of the head of the bed, revealed it was her idea and not a directive from the nurse. The CNA stated she checked on the resident approximately every 30 minutes as her work allowed, because she was worried about the resident. CNA #1 stated she went on a “quick break" and when she retumed CNA #2 was exiting resident #14’s room and she assumed he had answered a call light for her. CNA #1 stated she later checked on the resident and saw that an oxygen concentrator had been appiied to the resident and he/she was having "gurgling" breathing. CNA #1 stated she told LPN #4 about the gurgling and had told her about the gurgling more than once. Further interview revealed that CNA #1 was not directed by LPN #4 to do frequent monitoring or vital sign checks. CNA #1 stated she did not see LPN #4 enter the resident toom to do monitoring. When asked about seeing LPN #4 examine the resident, CNA #1 stated she never saw LPN #4 in the room until the resident passed. 7. Interview with CNA #2 on 7/29/04 at 1:48 PM revealed he worked in the same hall as CNA #1 and answered a call light in resident #14's room. Upon entering the room he discovered that resident #14's roommate had pushed the call bell for him/her. CNA #2 stated he could hear that resident #14’s was having trouble breathing and told LPN #4, who instructed him to take vital signs. CNA #2 stated resident #14’s vital signs were “abnormal” and that when he entered the residents room, the resident was observed to be clean, no vomit was noted. CNA #2 was asked by LPN #4 to assist In obtaining an oxygen concentrator and bring it to the resident's room. 8. Interview with LPN #5 on 7/29/04 at 3:58 PM revealed she worked the 11:00 PM to 7:00 AM shift and was on the same wing or side of the building with LPN #4. LPN #5 stated she has been a nurse for 1 month and at approximately 11:45 PM LPN #4 told her that resident #14 had vomited. LPN #5 stated she asked LPN #4 If she had called the family and the response was that it (the vomit) wasn't that much and the resident said "I feel fine”. LPN #5 stated that between 11:45 PM and 12:00 midnight she entered the room with LPN #4 and looked at the resident. LPN #5 stated the resident was lying in bed with the head of the bed elevated at a 45 degree angle and looked pale and his/her "Iips were a little blue”. She stated the resident "didn't look too good". LPN #5 stated when she asked LPN #4; "why not sent to the hospital?" the response was the resident is a "DNR" (Do Not Resuscitate). LPN #5 stated she never actually saw LPN #4 enter resident #14's room to do monitoring checks, but just saw her walk near the entrance of the hallway. LPN #5 also stated LPN #4 had mentioned calling the Doctor, but never actually saw or overheard the nurse speaking to him on the phone. Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 6 of 12 Bue a1 2505 16:55 POFSSE L448 SHCA GENERAL CDINSE_ Page os/13 9. Interview with LPN #4 on 7/29/04 at 10:10 AM revealed she was the nurse assigned to resident #14 and at 11:30 PM on Monday night and was told by a CNA that he/she had vomited his/her dinner. LPN #4 stated this was not uncommon for the resident and that he/she doesn't always take his/her medications. LPN #4 stated she asked the CNA to take the resident's vitals, which she stated "were not good, respiration was up and had a high pulse rate". LPN #4 stated around 11:45 PM or 12:00 midnight the resident had “gurgling sounds”, the head of the bed was up. LPN #4 stated she catled the Doctor and left a message and paged him. She stated when the doctor called her back she sald he told her to "keep an eye on (the resident)" and put oxygen on at 3 Liters per millimeter. Inquiry related to lack of documentation of the call to the doctor at the same general time as when the 12:00 midnight note was documented by her, returned the response, "I forgot to chart the call”. Inquiry related to her “checks” revealed she did visual checks only, did not take any further vital signs and did not document monitoring. She confirmed she did not write a physician telephone order slip for the oxygen because she thought she could just give it without an order. LPN #4 confirmed she never checked the resident's blood sugar or oxygen saturation percentage. 40. Interview with the facility's Medical Director on 7/29/04 at 9:55 AM revealed he was resident #14's attending physician and the resident had a history of occasional vomiting, but over the past 2 to 3 weeks the resident's overall health status had “leveled off". When questioned about possible interventions related to the situation described in the nurses notes dated 7/27/04 at 12:00 AM, he indicated that "if she (LPN#4) had called me “| would have told her to ensure that the resident was comfortable, assist with clearing the airway, and put O2 (oxygen) on. When asked if suctioning of the airway would have been extraordinary means, he responded “suctioning may have been appropriate” for resident #14. Inquiry related to monitoring of the resident revealed a typical monitoring schedule would be every 15 to 30 minutes. 14, Continued record review revealed a physician progress note dated 6/16/04 documenting resident #14 having a 3 pound weight gain, eating erratically and utilizing insulin “to cover" (blood sugar changes). The note documented general improvement of the resident and being more cooperative. Further review of physician progress notes revealed a note dated 7/15/04 documented resident #14 as being "mora comfortable, eats fair, improved with Haldol and more cooperative”. No new medications were order at this time or a change in the plan or care. 12. Review of the facility's Emergency Healthcare Policy dated 11/01/03 revealed "The center will be prepared to deliver emergency healthcare within the scope of practice of the Licensed Nursing staff’. The Process includes: a. Assess Customer (resident) b. Monitor vital signs c. Initiate appropriate medical interventions d. Document all assessments, processes and procedures utilized in the medical record. 14. Respondent's failure to provide necessary care and services is a violation of Rule 59A-4.1288, Fla. Admin. Code, which incorporates by reference 42 CFR 483.25. 15. AHCA classified the nature and scope of this violation as a class | “isolated” violation. Pursuant to Section 400.23(8)(a), this classification Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 7 of 12 Ble tl/2aH8 18:56 7275521440 6HO% GENERAL COUNSEL constitutes grounds for the imposition of an administrative fine of TEN THOUSAND DOLLARS ($10,000), A class | violation is defined as one that “the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility.” 16. Pursuant to Section 400.19(3), the above-noted class | violations constitute imposition of a six-month survey cycle fee of SIX THOUSAND DOLLARS ($6,000) upon Respondent. CLAIM FOR RELIEF WHEREFORE, the Agency respectfully requests the following relief: 1. Factual and legal findings in favor of the Agency on Counts | and MH. 2. imposition of administrative fines as follows: Count !, TEN THOUSAND DOLLARS ($10,000); Count II, TEN THOUSAND DOLLARS. 3. Imposition of a six-month survey cycle fee of SIX THOUSAND DOLLARS ($6,000), for a total of TWENTY-SIX THOUSAND DOLLARS ($26,000) in fines and fees. 4. Such other relief as this Court deems is just and proper. NOTICE Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569 and 120.57, 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 Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 8 of 12 Rivals Rans lasts P295S22448 SHCA GENERAL CONSE Pack 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. be) Respectfully submitted this H “day of_Q acted i = , 2005. Timothy B. Elliott, Senior Attomey Fla. Bar No. 0210536 Agency for Health Care Administration 2727 Mahan Drive, Building #3, MSC #3 Tallahassee, FL 32308 (850) 921-5873 (office) (850) 413-9313 (fax) Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8460 Page 9 of 12 A1eSl42983 16:56 7275521448 4HC8 GENERAL COUNSEL Pas&E 11/13 CERTIFICATE OF SERVICE | HEREBY CERTIFY 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 (receipt # 7004 1160 0003 3739 7524), to: Joyce Kadziolka-Long, Administrator, Ruleme Center, 2810 Ruleme Street, Eustis, Florida 32726, and by regular stamped U.S. Mail to Respondent's counsel, Alfred W. Clark, P.O. Box 623, Tallahassee, Florida rn 32302, this % “day of f acon __, 2005. Ton ©. Timothy B. Elliott, Senior Attorney Agency for Health Care Administration Administrative Complaint 2004007585 Certified Number 7106 4575 1294 2049 8480 Page 10 of 12

Docket for Case No: 05-000388

Orders for Case No: 05-000388