STATE OF FLORIDA an AGENCY FOR HEALTH CARE ADMINISTRATION oo AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2005001052 AHCA No.: 2005001051 v. Return Receipt Requested: 7002 2410 0001 4234 4288 BROOKWOOD GARDENS CONVALESCENT 7002 2410 0001 4234 4295 CENTER OPERATIONS, LLC, d/b/a BROOKWOOD GARDENS REHABILITATION AND NURSING CENTER, Respondent. 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 Brookwood Gardens Convalescent Center Operations, LLC, d/b/a Brookwood Gardens Rehabilitation and Nursing Center (hereinafter “Brookwood Gardens Rehabilitation and Nursing Center”), pursuant to Chapter 400, Part II, and Section 120.60, Fla. Stat. (2004), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $2,500.00 pursuant to Section 400.23(8), Fla. Stat. (2004), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Brookwood Gardens Rehabilitation and Nursing Center, pursuant to Section 400.23(7) (b), Fla. Stat (2004). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Fla. Stat. (2004), and Chapter 28-106, F.A.C. 4. Venue lies in Miami-Dade County, pursuant to Section 400.121(1) (e), Fla. Stat. (2004), 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., (2004), and Chapter 59A-4 Florida Administrative Code. 6. Brookwood Gardens Rehabilitation and Nursing Center is a 120-bed skilled nursing facility located at 1990 S. Canal Drive, Homestead, Florida 33035. Brookwooc. Gardens Rehabilitation and Nursing Center is licensed as a skilled nursing facility; license number SNF1064096; certificate number 12214, effective 12/22/2004, and certificate number 12215, effective 12/31/2004 through 12/30/2005. Brookwood Gardens Rehabilitation and Nursing Center was at all times material hereto a licensed facility under the licensing 2 authority of AHCA and was required to comply with all applicable rules and statutes. 7. Because Brookwood Gardens Rehabilitation and Nursing 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. COUNT I BROOKWOOD GARDENS REHABILITATION AND NURSING CENTER FAILED TO ENSURE THE RESIDENT’S ENVIRONMENT WAS FREE OF HAZARDS DURING TRANSFERS WITH MECHANICAL LIFTS LEADING TO INJURY FOR ONE OF FIVE SAMPLED RESIDENTS TITLE 42, SECTION 483.25(h) (1), Code of Federal Regulations, as incorporated by Rules 59A-4.1288, Florida Administrative Code CLASS II DEFICIENCY 8. AHCA xre-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During the appraisal visit conducted on 12/22/04 and based on record review and interview the facility failed to ensure the residents' environment was free of accident hazards during transfers with mechanical lifts leading to injury for one of five sampled residents. 10. Review of the clinical record for resident #4 (a cognitively impaired resident per facility assessment) revealed the resident was admitted to the facility with malignant hypertension, congestive heart failure, organic brain syndrome, peripheral vascular disease, depression, psychosis, osteoporosis, status post pacemaker insertion and status post deep vein thrombis. 11. Review of the "Nurse's Notes" dated 12/8/04 reveal the following entries: (a) "7:45am Called to (room #) by (licensed practical nurse's name) for report of large laceration. When entering room noted resident in Marisa lift with compound fracture of Rt (right) lower leg, bleeding profusely. Call out to 911. Rt lower leg splinted with linen and cradled in arms while resident was returned to bed from Marisa lift. Leg elevated and supported. Unable to obtain BP (blood pressure at this time. Pulse 87, 02 (oxygen) Saturation @97 or. room air. Resident's skin warm and dry, c/o (complained of) pain only when LRE (lower right extremity) was moved. (b) 8:10am 911 responders arrived, did evaluation, VS (vital signs) and re-splinted Rt lower extremity, bleeding decreased at this time. Pulse 80-84 (apical), R (respirations) 36, unable to get BP. Capillary refill determined az this time to be 2-3 seconds. Resident awake and responding in (language). Decision made by 911 responders to transport resident to regional trauma center. (c) 8:35am 911 responder transported resident via helicopter .." 12. Interview with the resident's family member who is serving as the resident's health care proxy on 12/22/04 at approximately 11:45 a.m. revealed he/she was notified of the transfer but not given information as to how the injury occurred. He/she further stated that this same leg had been fractured six months ago in June in another long term care facility followed by development of a deep vein thrombis and ensuing surgery to insert a vena cava umbrella to prevent pulmonary embolisms. The family member added that he/she had been told by a doctor at the trauma center for the recent injury that the resident also sustained a fractured left clavicle and that the resident remains on a ventilator at the present time. 13. During an interview with the Staff Education/Infection Control Nurse on 12/22/04 in the afternoon about the incident revealed that the facility investigated the incident by questioning the two Certified Nursing Assistants (CNAs) involved, who had reported that during the transfer of the resident from the shower chair to the wheel chair the resident's leg got caught in the Marisa lift as the resident was being lifted with blood found on the floor after the resident was placed on the wheel chair. 14. Review of the resident #4's roommate (resident #6) clinical record revealed the resident's roommate's most recent Minimum Data Set with reference date of 12/3/04 describes him/her as having intact short and long-term memory. The same document codes the roommates cognition as "1" indicating modified independence - some difficulty in new situations only." During an interview with resident #6 at 12:45pm on 12/22/04 he/she stated he/she did not know what happened but that "They put (him/her) in some kind of machine ard (he/she) yelled." 15. During an interview with the Administrator at approximately 2:00pm on 12/22/04 he was asked what measures had been taken after the incident. He stated they felt the problem might have been attributable to crowding because of all the equipment and furniture in the room (an extra wide wheelchair, shower chair, bed and high backed arm chair on the resident's side of a two-person room). Because of this, on 12/10/04 he sent a memo requiring the high backed chairs to be removed from the bedsides of resident's utilizing the Marisa lift as of that date and attached a list of names with room numbers. The two CNAs involved were suspended for five days without pay and reeducated on the lift usage when they returned. All staff was in-serviced on lift usage. The lift was examined by a manufacturer's representative and documented to be in good working order. 16. During a brief walk through of the facility shortly after the interview with the administrator a high backed chair was observed in a room occupied by a resident who is transferred with the Marisa lift as evidenced by the adhesive sticker on the resident's bed. This was confirmed with the charge nurse and the MDS Coordinator at this time. This information was related to the Administrator who supplied a list of the rooms in which the high backed chairs were removed on 12/10/04. This resident had not been admitted to the facility until 12/14/04 and the chair had not been removed from the room. The chair was subsequently removed after surveyor inquiry. 17. Review of the "Lift-Free Policies and Procedures" requested from and supplied by the facility stated, under the heading of "Patient Lift/Transfer," it stated: "Arrange the environment as necessary." Make sure there is appropriate space to maneuver and work in to ensure a safe lift, transfer or move." At approximately 3:00pm on 12/22/04 the Staff Education/Infection Control Nurse was asked if the policy xegarding lifts had been reevaluated. She stated "no" it was not considered to be necessary because this incident was deemed to be a "people problem rather than a policy problem or systems problem." 18. The facility staff failed to "Arrange the environment as necessary" and "Make sure there is appropriate space to maneuver and work in to ensure a safe, lift, transfer or move." In addition no systematic safeguards were put in place to ensure that new admissions requiring the use of this lift would have their rooms appropriately modified to prevent accidents/injuries. 19. Based on the foregoing, Brookwood Gardens Rehabilitation and Nursing Center violated Title 42, Section 483.25(h) (1), Code of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as an uncorrected Class III deficiency oursuant to Section 400.23(8)(c), Fla. Stat., which carries, in this case, an assessed fine of $2,500.00. 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, Brookwood Gardens Rehabilitation and Nursing 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 “A” 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 $2,500.00 against Brookwood Gardens Rehabilitation and Nursing Center on Count I. Cc. Assess and assign a conditional license status to Brookwood Gardens Rehabilitation and Nursing Center in accordance with Section 400.23(7) (b), 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 (2004). 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. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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 0! R BY THE AGENCY. odney \ Assistant General Coumsel 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 8355 NW 537? Street Miami, Florida 33166 (Interoffice Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 10

Docket for Case No: 05-001126