STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2004006032 2004005062 DELTA HEALTH GROUP, INC., “4 d/b/a MAITLAND HEALTH CARE CENTER, O*5- OS } \ 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 DELTA HEALTH GROUP. INC., d/b/a MAITLAND HEALTH CARE CENTER (hereinafter Maitland”), pursuant to §§ 120.569 and 120.57, Fla. Stat. (2004), and alleges: NATURE OF THE ACTION This is an action to change Maitland’s licensure status from Standard to Conditional, commencing November 4, 2004, and to impose an administrative fine in the amount of $1,000.00 based upon Maitland being cited with one uncorrected Class III deficiency. JURISDICTION AND VENUE l. 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 H, Fla. Stat., and Fla. Admin. Code R. 59A-4, respectively. 4. Maitland operates a |80-bed nursing home located at 1700 Monroe Avenue, Maitland, Orange County, Florida 32751, and is licensed as a skilled nursing facility under license number SNF 14280961. 5. Maitland 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 42 CFR § 483.20(k)(3)(i) and Fla. Admin. Code R. 59A-4.1288, the services provided or arranged by facilities must mect professional standards of quality. 8. Pursuant to 42 CFR § 483.25(m) and Fla. Admin. Code R. 59A-4.1288, facilities must ensure that residents are free of any significant medication errors. 9. On or about September 29, 2004, the Agency conducted a complaint investigation (complaint investigation #2004008569) at Maitland (the “Facility”). 10. During the investigation, Agency representatives toured the Facility, made observations, interviewed Facility staff, and performed record review. 11. Asa result of its investigation, the Agency has determined that Maitland failed to follow physician's orders for one of three sampled residents (Resident # 2). 12. Resident # 2 was admitted to Maitland from a local hospital on September 27, 2004, at 9:00 p.m. with a diagnosis of methicillin-resistant Staphylococcus aureus (“MRSA”), which was present in the resident’s sputum. 13. Resident # 2’s records contained medication and treatment orders from the hospital dated September 27, 2004. 14, The resident’s medication orders included vancomycin (an antibiotic) 1 gram by intravenous administration (IV) every 12 hours, with the next dose due at “0300” (3:00 a.m.). 15. Resident # 2's current Physician's Admission Orders, dated September 27, 2004, documented the following order: "vancomycin every 12 hours due 3 a.m. and 3 p.m.". 16. The Facility failed to document on Resident # 2"s medication administration record (“MAR”) that Resident # 2 had received the ordered vancomycin doses. 17. The Facility also failed to document that the physician's order was faxed or called to the pharmacy. 18. Resident # 2 resided on the Key’s Unit in the Facility. 19. Agency representatives conducted an interview with the Key’s Unit Manager/Assistant Director of Nursing (ADON) on September 29, 2004 at 9:40 a.m. 20. The ADON acknowledged that Resident # 2 had a physician’s order for IV vancomycin which had been ordered upon admission to the Facility and which still had not been obtained by the Facility. 21. Agency representatives observed Resident # 2 on September 29, 2004 at 10:00 a.m. and again at 10:45 a.m. on the Key's unit in her/his room. 22. Resident # 2 was not receiving any IV medication as of that date and time, and there was no evidence that Resident # 2 had received his/her medication prior to that date and time. 23. Facility staff documented “call placed to pharmacist [V department with regards to the resident’s 1V vanco (vancomycin) that was not delivered” in Resident # 2's Nurse's Notes dated September 29, 2004 at 9:45 a.m. 24. The resident’s physician was notified at 11:00 a.m. that the resident missed three doses of the vancomycin [V as ordered (vancomycin 1.0 gram IV every 12 hours for 10 days). 25. According to the resident’s record, the vancomycin arrived at 12:45 p.m. and administration of 1.0 gram was started at 1:00 p.m. through the resident’s right chest port. 26. According to the Facility’s records, the Facility dispensing pharmacy requirements (revision date October 1, 2003, “F”) documented that the pharmacy provided “routine and timely pharmacy and emergency pharmacy service 24 hours per day, seven days per week", 27. Review of Resident # 2's faxed copy of his/her Physician's Admission Orders, which was provided by the Director of Nursing (DON), revealed that the date the admission orders were faxed to the pharmacy was September 28, 2004 at 10:48. 28. According to the 3-11 shift Licensed Practical Nurse (“LPN”) on the Key’s unit, he/she faxed the physician’s admission orders to the pharmacy at approximately 10:00 p.m. on September 28, 2004. During the interview with the LPN, the administrator and DON were also present. 29. The Facility Administrator, DON, and the Key's Unit Manager/ADON confirmed that the physician’s admission orders had not been faxed to the pharmacy prior to 10:00 p.m. on September 28, 2004, and that the Facility failed to follow up with the pharmacy to ensure that Resident # 2's vancomycin was received and administered as ordered. 30. Therefore, Maitland failed to administer three IV doses of vancomycin to Resident # 2 as ordered since admission to the Facility on September 27, 2004. The first dose should have been given on September 28, 2004 at 3:00 a.m., the second dose should have been given at 3:00 p.m. on September 28, 2004, and the third dose should have been given at 3:00 a.m. on September 29, 2004. 31. Based on the foregoing, Maitland violated Fla. Admin. Code R. 59A-4.1288, 42 CFR § 483.20(k)(3)(i), and 42 CFR § 483.25(m). 32. The Agency determined that these conditions or occurrences have the potential to compromise the resident’s ability to maintain or reach his or her highest practicable physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care and provision of services, and cited this deficient practice as a isolated State Class III deficiency. 33. The Agency provided Maitland with a mandatory correction date of October 20, 2004, for this deficient practice. 34. On or about November 4, 2004, the Agency conducted a follow-up visit to the complaint investigation at Maitland. 35. During the follow-up visit to the complaint investigation, Agency representatives toured the Facility, made observations, interviewed Facility staff, and performed record review. 36. Based upon observation, interview and record review, the Agency determined that Maitland failed to follow physician's orders for onc of three sampled residents (Resident # 1) regarding medication administration. 37. According to Resident # 1’s records, the resident was admitted to the Facility on October 15, 2004 from the hospital with diagnoses of right inguinal lymphadenitis (right groin abscess) and Human Immunodeficiency Virus (HIV). 38. On October 21, 2004, Resident # 1’s physician ordered vancomycin 1.25 grams intravenously (IV) every 12 hours to treat the resident’s groin abcess. 39. Review of the resident’s MAR revealed that the vancomycin was to be given at 9:00 a.m. and 9:00 p.m. 40. Resident # 1 was observed by Agency representatives during the initial tour of the Facility on November 4, 2004 at 11:00 a.m. to be alert and oriented and located in his/her room. 41. A 250 milliliter bag of Normal Saline mixed with the vancomycin was found hanging on the IV pole beside Resident # 1’s bed with approximately 100 milliliters of fluid left in the bag. 42. The IV line coming from the bag of Normal Saline was disconnected from resident’s venous access, a peripherally inserted central catheter (PICC). 43. Interview with the staff nurse on duty revealed that the IV bag was left from the 9:00 p.m. dose the prior night. 44. The resident’s physician had ordered a vancomycin “trough” level to be completed prior to the resident’ s 9:00 a.m. dose of vancomycin to determine if the dosage needed to be altered. 45. The Facility staff failed to administer the resident’s 9:00 a.m. vancomycin dose. 46. Interview with the resident revealed that on several occasions medication fluids had been left in the TV bag with the IV line disconnected from the PICC line. The IV bags were then discarded with the medication fluids remaining in the bags. 47. On November 4, 2004, Agency representatives conducted an interview with the Pharmacist for the Facility who is responsible for preparing the medications. 48. The Pharmacist confirmed that the resident would not have received the full amount of antibiotic ordered by the physician if there was more than 50 -70 milliliters of fluid left in the IV bag following the administration of the Normal Saline mixed with the vancomycin dosage. 49. The resident’s vancomycin “trough” level, which was received on November 4, 2004 at 1:00 p.m., was below the normal range. 50. Interview with the Risk Manager and ADON confirmed that resident did not receive the full amount of antibiotic as ordered. 51. The Risk Manager and ADON also stated that on November 3, 2004, the resident’s 9:00 a.m. vancomycin dose was missed because the resident went on a leave of absence from the Facility and did not return until later in the day. 52. The 9:00 a.m. dose of the medication was never given nor was the time re- adjusted. 53. The Facility staff also failed to notify the resident’s physician of the missed antibiotic dose. 54. Based on the foregoing, Maitland violated Fla. Admin. Code R. 59A-4.1288, 42 CFR. § 483.20(k)(3)(i), and 42 CFR § 483.25(m). 55. | The Agency determined that these conditions or occurrences have the potential to compromise the resident’s ability to maintain or reach his or her highest practicable physical, mental. or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care and provision of services, and cited these deficient practices as an isolated uncorrected State Class III deficiency. 56. | The Agency provided Maitland with the mandatory correction date of November 26, 2004, for this deficient practice. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Maitland, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(c) and 400.102, Fla. Stat. (2004), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2004) COUNT II 57. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (56) as if fully set forth herein. 58. Based upon Maitland’s cited uncorrected State Class III deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute, 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 Maitland, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7)(b), Fla. Stat., commencing November 4, 2004. Respectfully submitted this _ \ pth day of January 2005. Kubery Yk caarnle-M n> Kimberly M. Nicewonder-Murray Fla. Bar. No. 571628 Agency for Health Care Administration §25 Mirror Lake Drive, 330D St. Petersburg, FL 33701 727.552.1435 (office) 727.552.1440 (fax) DISPLAY OF LICENSE Og ae Alt, Py Pursuant to § 400.23(7)(e), Fla. Stat. (2003), Respondent shall post the most curr Mee prominent place that is in clear and unobstructed public view, at or near, the place vie 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 0299 1846 on January At, 2005 to: James A. Richardson, II, Administrator, Maitland Health Care Center, 1700 Monroe Avenue, Maitland, Florida 32751, and U.S. Mail to: Sondra McCrory, Registered Agent, Maitland Health Care Center, 2 North Palafox Street, Pensacola, Florida 32502. (burly ™ rly) tine, ) saber . Nicewohder-Murray, Esquire Copies furnished to: James A. Richardson, I Sondra McCrory Kimberly M. Nicewonder- Administrator Registered Agent for Murray, Esquire Maitland Health Care Center Maitland Health Care Center Senior Attorney 1700 Monroe Avenue 2 North Palafox Street Agency for Health Care Maitland, Florida 32751 Pensacola, Florida 32502 Administration (U.S. Certified Mail) (U.S. Mail) 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701

Docket for Case No: 05-000575