STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2004011422 ~ 2004011423 THE PLACE AT MAITLAND, INC., d/b/a PLACE AT MAITLAND (THE), 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 THE PLACE AT MAITLAND, INC., d/b/a PLACE AT MAITLAND (THE) (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION This is an action to impose two administrative fines in the amount of $3,000.00 (includes two survey fees of $500.00) based upon two cited State Class II deficiencies ($2,000.00 fine) pursuant to §400.419(2)(b) Fla. Stat. (2004). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60 and 400.407, 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 assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part III, Florida Statutes, and; Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a 116-bed assisted living facility located at 740 N. Wymore Road, Maitland, Florida 32751, and is licensed as an assisted living facility, license number 9415. 5. Respondent was at all times material hereto a licensed 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 Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Fla. Admin. Code R. 58A-5.0182 8. That on November 22, 2004, the Agency conducted a complaint investigation of the Respondent facility. 9. That based upon review of records and interview it was determined that the facility failed to ensure that one of six sampled residents was provided with the appropriate care and interventions to prevent the resident from falling and sustaining a hip fracture. 10. That Petitioner’s representatives reviewed the Respondent’s resident records and incident reports. 11. That the Health Assessment form of resident number two, dated June 14, 2004, reflects that the resident suffers from dementia and frequent falls. 12. That a review of the Respondent’s adverse incident reports revealed the following information regarding resident number two: That on September 21, 2004, the resident was found laying on the resident's back on the floor with no injuries; That on September 27, 2004 the resident was found on the bathroom floor with no injury; That on September 30, 2004 the resident was found laying on the resident's back by the door; That on October 26, 2004 the resident suffered three falls, atl0:00 a.m., 12:00 p.m., and 2:45 p.m., and was found in the room having suffered a mild abrasion; That on November 5, 2004, the resident was at the table, eating standing up, and stretching over the chair spilling liquids. The resident lost balance and fell back when two resident assistants caught the resident before the resident’s head hit the floor. The assistants were able to get the resident up and into a chair where the resident sat and continued to eat; That on the same day the resident was found on the floor in the resident’s room by a family member. The resident was laying in urine and feces and very was afraid; That the resident was transported to the hospital where the resident was diagnosed with a hip fracture requiring surgery. That there was no documentation found in the adverse incident reports to indicate that any intervention was in place for the falls. That there was no documentation found in the residents other records which would indicate that the facility had made any efforts to take steps to place any interventions to address the resident's falls. 15. That the Petitioner’s representatives interviewed the Respondent’s director of nursing on November 22, 2004. 16. That the Respondent’s director of nursing indicated the following: a. That she was aware of the frequent falls experienced by resident number two but had not documented any conversations which addressed the falls; b. That resident number two suffered from frequent infections and the incidents of falling appeared to occur more often when the resident had an infection; c. That the Respondent had no service plan to address the frequent falls of resident number two; d. That the Respondent had not undertaken any further assessment of resident number two to ensure that the Respondent could provide adequate care and services for the resident; 17. That there were no interventions in place to address the frequent falls of resident number two. 18. That the Petitioner’s representatives interviewed a member of resident number two’s family on November 24, 2004. 19. That the resident’s family member indicated the following: a. That the facility had not spoken with the family member or otherwise indicated the frequent falls experienced by resident number two; b. That when the family member expressed a concern to the facility that the resident may need a higher level of care, the family member was assured that a higher level of care was not necessary and that the resident was doing better at the facility; c. That resident number two had sustained a hip fracture for which surgery was required; d. That the resident’s treating physician was unable to determine which fall caused the resident’s fracture due to the multiplicity of falls; e. That the resident now requires total care as a result of the fracture from falls and resides in a skilled nursing facility. 20. That the Respondent’s failure to assess and plan for interventions to prevent resident number two from falling after numerous falls by the resident constitutes failure of the Respondent to provide adequate care and services for the resident in violation of law. 21. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 22. | The Agency provided Respondent with a mandatory correction date of November 23, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT I 23. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (23) as if fully set forth herein. 24. That as a result of the Agency’s complaint investigation ending November 22, 2004, the Respondent was cited for one Class II deficiency which arose from the subject of the complaint. 25. That pursuant to Section 400.419(10), Florida Statutes (2004), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 400.428(3)(c), Florida Statutes (2004), to verify the correction of the violations. In this case, AHCA is authorized to request a survey fee in the amount of $500.00. WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla. Stat. COUNT III 26. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 27. Pursuant to Florida law, an assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility. Fla. Admin. Code R. 58A-5.0182. 28. That on November 30, 2004, the Agency conducted a complaint investigation of the Respondent facility. 29. That based upon review of records and interview the facility failed to provide care and services appropniate to the needs of residents regarding medications and failed to ensure that medication administration and assistance was free from errors and administered or assisted three of seven sampled residents with the incorrect medications, that is medications which had not been prescribed to the residents, which resulted in one resident’s hospitalization. 30. That the Petitioner’s representatives reviewed the Respondent’s resident records and adverse incident reports. 31. That the records reviewed revealed the following regarding resident number seven: a. That an adverse incident report dated April 2, 2004 reflected “Med tech apparently set medications on breakfast table and did not observed [sic] resident take their meds;” b. That the resident’s record reflected an order dated April 2, 2004 providing, “Monitor resident’s vital signs, send to ER with any significant changes in condition;” c. That anurse’s note dated April 2, 2004 documented that the resident’s guardian visited the resident and requested that the resident be sent to the emergency room as the guardian “...did not like pallor ~ resident quite pale;” d. That a progress note dated April 14, 2004 noted the resident was seen for a follow — up after a hospital stay resulting from a mistake with medications in which the resident was given another patient’s medications. The note continued that the resident “...spend several days in the hospital due to reaction to wrong medications.” 32. That there was no indication in the Respondent’s report or resident records of what type of medication(s) and what dosage was administered in error. 33. That the records reviewed revealed the following regarding resident number six: a. That an incident report dated November 19, 2004 annotated that a “medication error” was made with resident number six; b. That a note in the resident’s record dated November 19, 2004, recites that the resident “was given Flexiril 10 mg at around 5:15 PM, which was not prescribed for the resident;” c. That a physician’s order dated November 24, 2004 prescribed Lisinopril 2.5 mg daily;” d. That the resident’s medication observation record reflects that the resident did not receive the prescribed Lisinopril until November 28, 2004. 34. That the Petitioner’s representative interviewed the Respondent’s director of nursing and a staff member. 35. That the director of nursing indicated that the medication error was as a result of a med tech who was fairly new to the facility mistaking resident number six for a different resident. 36. That the staff person indicated that resident number six receives medications by mail order which caused the delay in the provision of the resident’s Lisinopril 37. That the records reviewed revealed the following regarding resident number two: a. That an incident report dated March 30, 2004 documents that in the morning a med tech reported to the nurse that the tech had given another resident’s medications to resident number two; b. That on March 30, 2004, at 12:45 PM, resident number two is noted to have complained of feeling sick to the resident’s stomach and felt like vomiting; c. That the resident was given Promethazine 25 mg.; d. That on March 30, 2004, at 1:10 PM, a note records that resident number two complained of stomach pain, but was feeling a little better; e. That a further note of March 30, 2004 at 1:35 PM documented "Med tech retumed from lunch, I informed [her/him] that resident was sick. I was going to a meeting. [She/he] informed me of the med error- DON, administrator and physician were notified;” f. That the entered order read, "not to send out but monitor BP and pulse, if rate below 55 or BP 120/70;" g. That subsequent notes documented the resident was placed by the nurse's station and vital signs were monitored. 38. That no written documentation was located which would indicate which medication or in what dosage such medication was provided in error to resident number two. 39. That the Petitioner’s representative interviewed the Respondent’s nursing supervisor. 40. That the Respondent’s nursing supervisor indicated that the staff member involved in providing the incorrect medication to resident number two was no longer employed with the facility. 41. That the same reflects the failure of the Respondent facility to provide care and services to the residents appropriate for the residents. 42. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 43. | The Agency provided Respondent with a mandatory correction date of December 1, 2004. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $1,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT IV 44. The Agency re-alleges and incorporates paragraphs (1) through (5) and (29) through (54) as if fully set forth herein. 45, That as a result of the Agency’s complaint investigation ending November 30, 2004, the Respondent was cited for one Class II deficiency which arose from the subject of the complaint. 46. That pursuant to Section 400.419(10), Florida Statutes (2004), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 400.428(3)(c), Florida Statutes (2004), to verify the correction of the violations. In this case, AHCA is authorized to request a survey fee in the amount of $500.00. WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla. Stat. Respectfully submitted this 24 _ day of January, 2005. owas J. Walsh, II . Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 727.552.1440 (fax) 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 Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308; Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7003 1010 0003 0279 4348 on JanuaryZ¢ , 2005 to Corporation Service Company, Registered Agent, The Place at Maitland, 1201 Hays Street, Tallahassee, Florida 32301-2525, and by U.S. Mail to Thomas Campbell, Administrator, The Place at Maitland, 740 N. Wymore Road, Maitland, Florida, 32751. Thowfas f. Walsh, [I _ nfer Attorney Copies furnished to: Corporation Service Company | Thomas Campbell Thomas J. Walsh, Registered Agent Administrator Agency for Health Care Admin. Place at Maitland (The) Place at Maitland (The) 525 Mirror Lake Drive, 330G 1201 Hays Street 740 N. Wymore Road St. Petersburg, Florida 33701 Tallahassee, FL 32301-2525 Maitland, FL 32751 (Interoffice) (U.S. Certified Mail) (U.S. Mail) PAYMENT FORM Agency for Health Care Administration 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. The Place at Maitland 2004011422/2004011423 Facility Name AHCA No.

Docket for Case No: 05-000925