“Bg pre a. Len STATE OF FLORIDA OS MAR - : AGENCY FOR HEALTH CARE ADMINISTRATION 4PM &: 35 AGENCY FOR HEALTH CARE Af ; ADMINISTRATION, Ri Petitioner, AHCA No.: 2004006034 AHCA No.: 2004006033 Return Receipt Requested: Vv. 7002 2410 0001 4237 1512 AYINTOVE ASSOCIATES, LLC, d/b/a 7002 2410 0001 4237 1529 HARMONY HEALTH CENTER, 7002 2410 0001 4237 1536 Respondent. / OS 0) \ (| (| ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Ayintove Associates, LLC, d/b/a Harmony Health Center (hereinafter “Harmony Health Center”), pursuant to Chapter 400, Part II, and Section 120.60, Fla. Stat. (2003), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $5,000.00 pursuant to Section 400.23(8), Fla. Stat. (2003), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Harmony Health Center, pursuant to Section 400.23(7) (b), Fla. Stat (2003). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat. (2003), and Chapter 28-106, F.A.C. 4. Venue lies in Miami-Dade County, pursuant to Section 400.121(1)(e), Fla. Stat. (2003), and Rule 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Fla. Stat., (2003), and Chapter 59A-4 Florida Administrative Code. 6. Harmony Health Center is a 203-bed skilled nursing facility located at 9820 North Kendall Drive, Miami, Florida 33176. Harmony Health Center is licensed as a skilled nursing facility; license number SNF1249095; certificate number 11528, effective 05/26/04 through 08/31/04. Harmony Health Center 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. 7. Because Harmony Health Center participates in Title XVIII or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, F.A.C. 2 COUNT 1 HARMONY HEALTH CENTER FAILED TO IMPLEMENT THEIR OWN POLICIES AND PROCEDURES FOR ACCURATELY INVESTIGATING AND REPORTING POTENTIAL CASES OF STAFF TO RESIDENT ABUSE AND NEGLECT WHO WAS INJURED AND SUSTAINED A FRACTURE REQUIRING HOSPITALIZATION FOR ONE OF FIVE SAMPLED RESIDENTS TITLE 42, SECTION 483.13(c), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code (STAFF TREATMENT OF RESIDENTS) CLASS II DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During a complaint investigation conducted on May 26, 2004 and based on record review and interview the facility failed to follow their own policies and procedures for accurately documenting and reporting adverse incidents, causing sampled resident R4's injury to be inappropriately investigated. 10. Based on record review and interview the facility failed to implement their own policies and procedures for accurately investigating and reporting potential cases of staff to resident abuse and neglect who was injured and sustained a fracture requiring hospitalization for one of five sampled resident's (#4). 11. Resident #4 was admitted to the facility on 11/27/02 and was readmitted on 05/19/04. On 05/11/04 at 8:45 pm the resident fell while receiving care from the Certified Nursing Assistant (CNA). A review of the nurses' notes that is currently in the chart states "found patient on the floor on her left side beside her bed, assessment done, bruise on left elbow, redness on her left shoulder." A further review of the record indicated that the resident suffered a left hip fracture, which required the resident to be sent to the hospital for surgery. 12. On 05/25/04 the complainant faxed a copy of the original record and the amended copy to the Agency for Health Care Administration (AHCA). The handwriting in both examples was similar and on 05/26/04, at approximately 5:05 pm, the Director of Nursing (DON) of the facility confirmed that the author of both versions were the same and identified the author by name. A review of the faxed record reveals that a Certified Nursing Assistant (CNA), who was identified by the DON at 5:05 pm, was cleaning up the patient while she was standing on both feet and holding on to the table. The patient's knees gave way and fell to the floor on her left side, an assessment was done and a bruise was noted on the left elbow and painful to touch. The facility's DON, who also serves as the Risk Manager (RM) , submitted a 1-day report to the AHCA on 05/14/04. The report stated that the resident was found lying on the floor. There is no mention of the CNA involvement regarding the fall and injury to the resident. On the 15-day report, which was submitted to AHCA on 05/21/04, under heading C: Adverse Incident, "the incident was not an adverse incident." Under the heading "Analysis and Corrective Action," the narrative states, “After a complete investigation the incident, the incident was not an adverse incident." 13. On 05/26/04 at 4:58 pm the DON was asked about the different versions of the incident. She confirmed that the original version was accurate but stated that, "The first version is part of my internal investigation. It does not belong in the chart." She was then asked why the correct sequence of information was not submitted to AHCA. She did not respond but offered to share the information on their internal incident report so that she could demonstrate that the incident was accurately investigated. However, when the report was read aloud by the DON, the information coincided with the amended documentation that was found in the medical chart. The DON confirmed at this time that AHCA should have been advised about the original version since it involved possible abuse and/or neglect of a staff toa resident. 14. On 05/27/04, the DON faxed a copy of the CNA's incident report, written in Spanish, and dated 05/26/04, same day of the complaint investigation. The report was translated verbatim by a Spanish speaking AHCA employee. The CNA makes reference to the resident being hurt but does not include her involvement or presence with the incident occurred. The note states, "We are aware of him/her, but in life there are moments that are inevitable. Not always, we remain with the same patient, and at a given moment when I was returning to room ----, since I was checking on other patients, I found the patient on the floor. I immediately run out to ask for help to the nurse." However, review of the nursing note found in the medical record dated 5/11/04 at 8:45 p.m. as written does not indicate that it was the CNA who found the resident on the floor or mention CNA's involvement in any way. 15. A review of the facility's Abuse Policy and Procedure under External Reporting of Potential Abuse, "the facility will report all allegations of abuse to the Department of Children and Families (DCF) and Adult Protective Services (APS) shall be informed immediately (within 24 hours) ." However, the facility confirmed that they failed to call APS or DCF and as a resuit no potential investigation was generated by either of these agencies. It further states that administrator or designee will also inform the resident or the resident's representative of the report of an occurrence or potential mistreatment and that an investigation is being conducted. A review of the facility's record revealed that the family was notified of the resident's condition on 05/11/04 at 2:15 am. There is no mention of an investigation or the family being advised of the nature of the incident as required. " Under the heading: Protection of Residents, the policy states "Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the administrator or designee has reviewed the results of the investigation." There is no evidence that the facility attempted to do so since the facility did not investigate the incident for potential abuse and/or neglect. In addition, the facility report of the incident to AHCA did not mention the CNA's involvement with the incident. 16. Based on the foregoing, Harmony Health Center violated Title 42, Section 483.13(c), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as an isolated Class II deficiency pursuant to Section 400.23(8) (b), Fla. Stat., which carries, in this case, an assessed fine of $5,000.00 (fine is doubled this time due to citing of Class I & II on 12/05/2003 annual survey and complaint investigation). This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Harmony Health Center shall post the 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. The Conditional License is attached hereto as Exhibit wan CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $5,000.00 against Harmony Health Center on Count I. c. Assess and assign a conditional license status to Harmony Health Center in accordance with Section 400.23(7) (bo), Florida Statutes. D. 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 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 for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922-5873. TILED oy RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE O5 MAR ~ REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF HAR, COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGE] j BE ARIIES IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. } | - / Xo son E. Rodney t FL Bar No: 178081 Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52°? Terrace Miami, Florida 33166 Copies furnished to: Diane Lopez Castillo Field Office Manager Agency for Health Care Administration Manchester Building 8355 N.W. 537% Street Miami, Florida 33166 (U.S. Mail) Jean Lombardi Pinance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32303 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) EXHIBIT “A” Conditional License License No. SNF 1249095 Certificate No. 11528 Effective date: 05/26/2004 Expiration date: 08/31/2004

Docket for Case No: 05-000844