$210v040ex- DrBULUK GADUN & KUSEN 1410027020 Oe STATE OF FLORIDA “SAD AGENCY FOR HEALTH CARE ADMINISTRATION _ STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA NO.: 2005000590 2005000591 v. aa . HEARTHSTONE SENIOR COMMUNITIES, 0 » - \ 4 | \ INC., d/b/a BAY CENTER, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the AGENCY FOR HEALTH CARE ADMINISTRATION (*“AHCA”), by and through its undersigned counsel, and files this Administrative Complaint against Hearthstone Senior Communities, Inc., d/b/a Bay Center (“Bay Center”) pursuant to Fla. Stat. Sections 120.569 and 120.57 (2004), alleging: | NATURE OF THE ACTION 1, This is an action to impose an administrative fine against Bay Center in the amount of Thirty Five Thousand Dollars ($35,000.00), the imposition of a Six Thousand Dollar ($6,000) survey fee and the imposition of a conditional license for two class I and one class II deficiencies pursuant to Fla. Stat. Section 400 and Fla. Admin. Code Chapter 584-14. gs ves las 2uu0 10:44 PAA 1Z2/39040U4 SFEULUK GADUN & KUSEN (00357020 JURISDICTION AND VENUE 2. This Agency has jurisdiction pursuant to Fla. Stat. §§ 120.569 and 120.57 (2004). 3. Venue lies in Bay County, Panama City, Florida, pursuant to Fla. Stat. § 120.57 (2004), and Fla. Admin. Code Chapter 58A~4 (2004). PARTIES 4. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities pursuant to Fla. Stat. Chapter 400, Part II (2004), and Fla. Admin. Code Chapter S9A-4 (2004). 5. Bay Center is a Florida corporation, which owns a 160-bed skilled nursing facility located at 1336 St. Andrews Boulevard, Panama City, Florida. The facility is owned by Hearthstone Senior Communities, Inc., and is licensed as a skilled nursing facility, license #10340961, certificate number 11177, effective April 1, 2004 through March 31, 2005. Bay Center is and was, at all times material hereto, a licensed facility under the licensing authority of AHCA, and required to comply with all applicable rules, and statutes. COUNT I THE RESPONDENT FAILED TO MONITOR BLOOD GLUCOSE LEVELS OF INSULIN DEPENDENT DIABETICS, IN ACCORDANCE WITH PHYSICIAN ORDERS, AND FAILED TO ADMINISTER INSULIN AND ORAL DIABETIC AGENTS, IN ACCORDANCE WITH PHYSICIAN ORDERS AND PROFESSIONAL STANDARDS OF PRACTICE, FOR 5 OF 28 RESIDENTS WITH A DIAGNOSIS OF DIABETES MELLITUS Fla. Admin. Code R. 59A-4.1288 (2004) §400.23(8)(a), Fla, Stat. (2004) 2 G5714/ZUUd 13:24 FAR 7273964604 SPEULYUR GADUN & KUSEN §400.23(7)(b), Fla. Stat. (2004) 42 CFR. §483.25(1)(2)(2004) 6. AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. wyuvE ULE 7. On or about January 7, 2005, AHCA conducted an annual survey at the Respondent's facility. AHCA cited the facility based on the findings below, to wit: 1. - During medication pass observation on 1/5/05 at 7:44 p.m. on Unit 2 the Licensed Practical Nurse #1 (LPN) was observed to awaken resident #25 from a sound sleep to perform a finger stick blood sugar and administer Novolin R 12 units based on an order for sliding scale ingulin to be administered at 4:30 P.M. An interview with the LPN at this time confirmed the finger stick blood sugar with insulin administration was ordered for 4:30 P.M. but was not performed until 7:44 P.M. An interview with. the Dietary Assistant Manager on 1/6/05 at 8:45 AM. stated the resident receives the evening meal at approximately 5:20 P.M. The insulin was administered over 2 hours after the resident had eaten. The LPN #1 on 1/5/05 was then observed to administer Lantus 15 units to resident #25 at 8:00 P.M. A review of the medication administration record and the signed physician order for 1/5/05 revealed the Lantus insulin was ordered to be given-at 6:00 P.M. An interview with the LPN af this time confirmed the medication was administered 2 hours after the physician ordered time of 6:00 P.M. A review of the medication administration record for resident #25 lists the resident was to receive sliding scale insulin on 1/5/05 at 4:30 P.M. and again at 9:00 P.M. The 4:30 PM. sliding scale insulin was not administered until 7:44 P.M. The LPN documented the resident refused the 9:00 P.M. finger stick blood sugar and sliding scale insulin for 1/5/05. A review of the medical record for resident #25 revealed the resident's blood sugars 1/1/05 to 1/5/05 ranged from 31 to 398. An interview with the physician on 1/6/05 at 10:45 A.M. confirmed the resident was on sliding scale insulin and had a history of uncontrolled diabetes. The physician stated he was not aware blood sugars and sliding scale insulin was not being completed at the times he ordered. According to Davis's Drug Guide, Lantus insulin has an onset time of 1.1 br, peaks at 5 hours and has a duration of 24 hours. The insulin lowers the glucose (blood sugar) and is used to control blood glucose levels in individuals with insulin-dependent diabetes mellitus. The medication is not effective in controlling blood sugar levels if not administered every 24 hours as ordered, The failure to perform glucose monitoring and sliding scale insulin administration as ordered by the physician is a significant medication error. The failure to administer the Lantus insulin as ordered by the physician is a significant medication error. 2.During a medication pass ‘observation on 1/5/05 at 7:25 P.M. on Unit 2 the LPN #1 was observed to perform a finger stick blood sugar and administer Novolin R insulin, 3 units, to resident #26. The blood sugar result wes 206. The finger stick blood sugar and sliding scale insulin were ordered to be given at 4:30 P.M. An interview with the LPN at this time confirmed 3 Oss taszuud 13:25 PAA 7Z789b4bU4 SPECLUR GADUN & KOSEN gWuuoruzu the finger stick blood sugar with sliding scale insulin administration was ordered for 4:30 P.M. but was not performed until 7:25 P.M. The failure to perform glucose monitoring and sliding scale insulin administration as ordered by the physician is a significant medication error. An interview with the Dietary Assistant Manager on 1/6/05 at 8:45 A.M. stated the resident receives the evening meal at approximately 6:20 P.M. The insulin was administered approximately 1 hour after the resident had eaten. ’ A review of the resident #26's medication administration record for 1/1/05 to 1/5/05 revealed _____there was no documentation of finger stick blood sugar and sliding scale insulin administration for 6:30 A.M. on 1/2/05. The resident was ordered finger stick blood sugars twice a day at 6:30 AM. and 4:30 P.M. with sliding scale insulin coverage. The failure to provide evidence of the completion of the finger stick blood sugar and administration of sliding scale insulin is a significant medication error. The resident's blood sugars ranged from 110 - 236 from 1/1/05 - 1/5/05. 3. During a medication pass observation on 1/5/05 at 6:35 P.M. on Unit 2, LPN#] wes observed to perform a finger stick blood sugar and administer Novolin R insulin, 2 units, to resident #22. The resident had completed the evening meal prior to the administration and the empty tray was observed on the bedside table. The finger stick blood sugar and sliding scale insulin were ordered for 4:30 P.M. The blood sugar was 201. An interview with the LPN at this time confirmed the finger stick blood sugar with sliding scale insulin administration was ordered for 4:30 P.M. but was not performed until 6:35 P.M. The failuge to perform the finger stick blood sugar and administer the insulin at the time ordered by the physician is a significant medication error. : An interview with the Dietary Assistant Manager on 1/6/05 at 8:45 A.M. stated the resident received the evening meal at approximately 5:20 P.M. The insulin was administered approximately’1 hour after the resident had eaten. A review of the resident #22's medication administration record for 1/1/05 to 1/5/05 revealed the resident was ordered finger stick blood sugar and sliding scale insulin coverage twice a day at 6:30 A.M. and 4:30 P.M. The resident's blood sugars from 1/1/05 to 1/5/05 revealed were 91- 136 requiring no insulin administration until the medication observation on 1/5/05 at 6:35 P.M., when the blood sugar increased to 201. 4. According to Mosby's Drug Reference, the onset time for Novolin R insulin is 1/2 hour with a peak in 4-8 hours. The action of the Novolin R insulin is to decrease the blood sugar (glucose) by transporting insulin into the celis. The sliding scale Novolin R insulin is ordered to be given prior to mealtime at 4:30 P.M. in order for the onset of the action to ogcur while there is food in the digestive system If the medication is given with no food in the system then there is the potential for the blood sugar level to become too low resulting in coma or death. . According to Lippincott, Manual of Nursing Practice, the normal range of blood glucose levels is "60 to 110." “Accurate determination of capillary blood glucose (finger stick blood sugar) assists patients in the control and daily management of diabetes mellitus." “Blood glucose monitoring helps evaluste effectiveness of medication...” "Medication regimens and meal timing are considered to set the most effective monitoring schedule." "Patients...may. test (glucose levels) before meals and at bedtime.” The Lippincott manual states Regular Insulin added to the diabetic medication regimen assists with postprandial glucose control. Short-acting insulin (Novolin R) added in the morning controls glucose elevations efter breakfast and "increased blood ghicose levels after supper can be controlled by the addition of short-acting 4 ~ 0371472005 13:25 FAX 7278964604 SPECLUK GADUN & KUDEN WeuvOorucU insulin before supper.” Regular insulin given before breakfast and before supper provides 24- hour insulin coverage for diabetic residents. 5. A review of the facility’s procedure for "Medication Administration-General Guidelines” reveals the nurse is to administer the medications "in accordance with written orders of the attending physician..and compliance with professional standards.” "Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered precisely as ordered.” 6. ‘An interview with the LPN #1 from the medication pass on Unit 2 on 1/5/05 at approximately 8:35 P.M. she stated Unit 2 has 39 residents and the normal staffing is one nurse and 2-3 CNA The LPN stated she had just completed at 8:35 P.M. the administration of the medications ordered from 4:30 P.M. thru 6:00 P.M. She was taking a short break before resuming with the 9:00 P.M. medication pass. The LPN states Unit 2 previously had a second nurse until "corporate" cut the nursing position, The LPN states the medication pass for Unit 2 is "horrible" “on a good night." The LPN states the nursing duties include medication pass, treatments, supervision of the CNAs, resident care, charting, dining duties and other duties. The LPN stops the medication pass at 5:20 P.M. to monitor the dining room on Unit 2 then resumes medication pass. 7.During an observation of medication pass on 1/6/05 at 6:15 P.M., LPN/Unit Manager was observed to review the Medication Record Administration and stated had "forgot" to give the Glyburide 5 mg on 1/6/05 at 4:30 P.M. for resident # 44. The LPN/Unit Manager asked the surveyor if she should give the medication. The surveyor questioned the nurse on the facility's policy and procedure on administering medications that are forgotten or given later than the time ordered by the physician. The LPN stated she did not know and would have to "look it up." The LPN went to the Assistant Director of Nurses (ADON) and questioned what she should do. The LPN returned and stated the ADON said to give the medication. The nurse then administered the medication at 6:20 P.M. to the resident, which was approximately 2 hours after the physician ordered the medication. A review of the medical record reveals the resident should receive the medication at the physician ordered times of 6:30 A.M. and 4:30 P.M. via a Gastrotomy tube. This is a significant medication error. 8, Observation of medication pass on 1/5/05 beginning at 6:11 PM on Unit 100 revealed that Resident #45's medication Glyburide 2.5-500mg was ordered for 5:00 PM and was administered at 7:00 PM.., this is a significant medication error. 9. ‘An interview with LPN #2 (who works Unit 1 or Unit 2 on the 3-11 shift), on 1/5/05 at 2:00 P.M. and 1/6/05 at 8:50 P.M. he stated the med pass for the 5 P.M. medications on Unit 1 and Unit 2 is begun at 4:00 P.M. to 4:30 P.M. The LPN #2 stated the nurse on Unit 1 and Unit 2 must stop medication pass at 5:20 P.M. and complete dining duties for approximately 1 hour. The 3-11 shift does not have a CNA to assist with dining duties and the nurse must stay until dining is completed. The medication pass is resumed after the dining and the medications for 5 P.M. are administered after 6:20 P.M., which is over the allowed I-hour timeframe for medication administration. The.LPN #2 stated medication pass takes approximately 3-4 hours for 39 residents "interruptions, emergencies, admissions” dining and other duties. The combined medication passes of 5:00 P.M. and 9:00 P.M. takes until 10:30 P.M. for Unit 2. The LPN stated the Unit 1 bas the same problem, The LPN stated often completes 5:00 P.M. medication pass at 7:00-7:30 P.M. The Unit 1 has 2 nurses on 3-11 shift but one nurse is pulled for dining duties. | The LPN stated he has reported the staffing and medication concerns to the administrator without a resolution. Vos ies cuua Las £29 PAA (£/39040U4 SrELCLUK GAVUN & KUSEN 10. An interview with the Director of Nurses (DON) on 1/6/05 at 12:15 P.M., she stated the routine staffing of Unit 2 for the 3-11 shift is 1 nurse. The DON stated the facility had a second nurse for the unit but the position was cut because of corporate requirements for nursing staff. The DON stated the staffing cut was made approximately 2 months ago but was unable to provide documentation of the specific date of the staffing cuts. The DON stated the facility could not have the Unit Managers and the extra nurse, so the extra nursing position for Unit 2 was deleted. The dining duties are covered by the Unit Managers on breakfast and lunch, but the 3-11 P.M. floor nurse covers the dining duties for their unit. The DON stated wheri the nursing staff was decreased; Hall 4 (which is a 26 bed umit) adjusted their treatment and _medication times to accommodate the dining duties. The DON acknowledged she had considered making similar changes for the 200 hal! on 3-11 Shift, buf had not followed up on this due to some resistance from a long time LPN floor nurse on the 200 hall who felt there may be other options. The DON stated she has not discussed any of these other options with the LPN, and no action has been taken to resolve the problem. The normal staffing for Unit 1 with 42 beds is 2 nurses on the 3-11 shift. One of the nurses on the 3-11 shift covers the evening dining duties in the main dining room. Ll. An interview with the administrator on 1/6/05 at 12:30 P.M. repeated the information given by the DON on 1/6/05 at 12:15 P.M. The administrator denies anyone notifying her of problems with the completion of medication pass or other duties. The administrator further stated she had no idea that medication pass was taking so long on the 200 hall, and the first time she was aware of a problem was on 1/5/05 when she stayed at the facility to observe medication pass with surveyors present. This statement was a contradiction of the statements made by LPN #2, who stated he complained strongly to the Administrator about the time management problems with one nurse attempting to complete medication pass, dining duties, and other required duties on the 3-11 shift. He states he was plainly told the reason corporate had denied the extra nursing position was because of nursing staff cut backs 12. During an observation of medication pass on Unit 200 on 1/6/05 at 4:00 P.M. revealed the unit had been split into two sections with a medication cart for each section, leaving two nurses to cover 39 residents, a duty normally assigned to one nurse. The medication pass began at 4:00 PM for one cart and 4:10 PM for the second cart. The pass was completed at 6:35 PM and 6:30 PM, respectively. Neither of the nurses dog medication pass were required to attend to dining room duty during this pass, a duty normally assigned to the medication nurse. The combined time for both nurses completing medication pass totaled 2 hours and 55 minutes, still outside the aHowed parameters of a 2-hour medication pass. This time does not include the time, which would normally have been spent supervising dining, which would add approximately another hour to the overall time. . . 13. An interview with a Registered Nurse on 1/7/05 at 7:00 A.M. she stated the Unit 1 and Unit 2, 3-11 P.M. nurses must stop 5:00 P.M. medication pass at 5:20 for dining duties and then resume medication pass resulting in late medications. The Registered Nurse stated there was not a CNA to assist with the Dining Duties and the nurse must stay to the completion of the dining. She was concerned with the dining interrupting the medication pass. 14, The observations of medication pass, physician orders, and the facility's medication administration records revealed a total of 7 significant medication errors. The facility's failure to monitor blood glucose levels of Insulin dependent diabetic residents, administer insulin and oral diabetic agents in accordance with physician orders placed the residents at a high risk for harm or death. The administrator was notified of an Immediate Jeopardy situation at approximately 10:30 am CST on 01/06/2005. At approximately 1:30 pm on 01/07/2005, the administrator notified the 6 (007/020 Vos ia/ZUUD 10:40 PAA 12foN040u4 O2rEULUK GADUN & KUDSEN WJUUBsSUZU survey team of the following corrective actions: an additional licensed practical nurse will be added to the Unit 2 hall to assist with medication pass; all nursing personnel will be re-inservice on medication pass procedures; and management staff will conduct quality assurance observations to ensure timeliness of medication administrations. 8. The deficiency was cited as a class I violation and AHCA mandated a correction date of February 6, 2005. A class I deficiency is defined as: a deficiency the Ageticy determines presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause serious harm, impairment, or death to a resident receiving care in the facility. he condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the Agency, is required by correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency...[{A] fine must be levied notwithstanding the correction of the deficiency. §400.423(8)(a) Fla. Stat. (2004) A conditional license may be imposed upon the Respondent based upon the class J deficiency. Conditional licenses may be imposed as follows: A-conditional license status means that the facility, due to the presence of one or more class I or class Il deficiencies, or class III deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with the criteria established under this part or with the mles adopted by the agency. : §400.423(7)b), Fla. Stat.(2004) 9. The above constitutes a violation of Fla. Admin. Code Section 59A- 4.1288(2004), stating: 59A-4.1288 Exception. Nursing homes that participate in Title XVIII or XIX umst follow certification rules and regulations found in 42 C.F.R. 483, Requirements for Long Term Care Facilities, September 26, 1991, which is incorporated by reference. 10. The violation alleged herein constitutes a class I violation, and warrants a fine of $15,000.00 and imposition of a conditional license. US/14/ZUU3 1SiZ20 FAA 1 Z2/8Y840U4 SPEUIUK GADUN & KUSEN 1 COUNT 0 ‘THE FACILITY FAILED TO PROVIDE SUFFICIENT NURSING STAFF TO MEET THE RESIDENTS’ NEEDS FOR 40 OF 65 SAMPLED RESIDENTS Fla. Admin. Code Section 59A-4.108(4)(2004) §400.23(8)(a), Fla. Stat. (2004) §400.23(7)(b), Fla. Stat.(2004) womens AQ CORORS jees— - 11. AHCA tealleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 12. On or about January 7, 2005, AHCA conducted an annual survey at Respondent’s facility. AHCA cited the facility based on the findings below, to wit: 1 On 1/5/05 an informal confidential complaint was called to the State Field Office from a Staff Member of the facility. The staff member stated the 3-11 P.M. shift on Unit 2 is understaffed and the nurses are administering medications after the allowed 60-minute time frame. 2. During medication pass observation on 1/5/05 at 7:44 p.m. on Unit 2 the Licensed Practical Nurse #1 (LPN) was observed to awaken resident #25 from a sound sleep to perform a finger stick blood sugar and administer Novolin R 12 units based on an order for sliding scale insulin to be administered at 4:30 P.M. An interview with the LPN at this time confirmed the finger stick blood sugar with insulin administration was ordered for 4:30 P.M. but was not performed until 7:44 P.M. ‘An interview with the Dietary Assistant Manager on 1/6/05 at 8:45 A.M. stated the resident teceives the evening meal at approximately 5:20 P.M. The insulin was administered over 2 hours after the resident had eaten. : ‘The LPN #1 on 1/5/05 was then observed to administer Lantus 15 units to resident #25 at 8:00 P.M. A review of the medication administration record and the signed physician order for 1/5/05 revealed the Lantus insulin was ordered to be given at 6:00 P.M. An interview with the LPN at this time confirmed the medication was administered 2 hours after the physician ordered time of 6:00 P.M. . A review of the medication administration record for resident #25 _ lists the tesident was to receive sliding scale insulin on 1/5/05 at 4:30 P.M. and again at 9:00 P.M. The 4:30 P.M. sliding scale insulin was not administered until 7:44 P:M. The LPN documented the resident refused the 9:00 P.M. finger stick blood sugar and sliding scale insulin for 1/5/05. A review of the medical record for resident #25 revealed the resident's blood sugars 1/1/05 to 1/5/05 ranged from 31 to 398. . juuysuZzU Vora evue 109,50 PAA i4founse0Ue DPrBULUNR GAVUN & KUOEN An interview with the physician on 1/6/05 at 10:45 A.M. confirmed the resident was on sliding scale insulin and had a history of uncontrolled diabetes. The physician was not aware blood sugars and sliding scale insulin was not being completed at the times he ordered. According to Davis's Drug Guide, Lantus insulin has an onset time of 1.1 hr, peaks at 5 hours and has duration of 24 hours. The insulin lowers the glucose: (blood sugar) and is used to control blood glucose levels in individuals with insulin-dependent diabetes mellitus. The medication is not effective in controlling blood sugar levels if not administered every 24 hours as ordered. 3. During a medication pass observation on 1/5/05 at 7:25 P.M. on Unit 2 LPN #1 was observed to perform a finger stick blood sugar and administer Novolim R insulin, 3 units, to resident #26. The blood sugar result was 206. The finger stick blood sugar and sliding scale insulin were ordered to be given at 4:30 P.M. An interview with the LPN at this time confirmed the finger stick blood sugar with sliding scale insulin administration was ordered for 4:30 PM. but was not performed until 7:25 P.M. An interview with the Dietary Assistant Manager on 1/6/05 at 8:45 A.M. stated the resident receives the evening meal at approximately 6:20 P.M. The insulin was administered approximately 1 hour after the resident had eaten. A review of the resident #26's medication administration record for 1/1/05 to 1/5/05 revealed there was not documentation of finger stick blood sugar and sliding scale insulin administration for 6:30 A.M. on 1/2/05. The resident was ordered finger stick blood sugars twice a day at 6:30 A.M. and 4:30 P.M. with sliding scale insulin coverage. The resident's blood sugars ranged from 110 - 236 from 1/1/05 - 1/5/05. 4. During a medication pass observation on 1/5/05 at 6:35 P.M, on Unit 2 the LPN#1 was observed to perform a finger stick blood sugar and administer Novolin R insulin, 2 units, to resident #22. The resident had completed the evening meal prior to the administration and the empty tray was observed on the bedside table. The finger stick blood sugar and sliding scale insulin were ordered for 4:30 P.M. The blood sugar was 201. An interview with the LPN at this time confirmed the finger stick blood sugar with sliding scale insulin administration was ordered for 4:30 P.M. but was not performed until 6:35 P.M. An interview with the Dietary Assistant Manager on 1/6/05 at 8:45 A.M. stated the resident received the evening meal at approximately 5:20 P.M. The insulin was administered approximately 1 hour after the resident had eaten. A review of the resident #22's medication edministration record for 1/1/05 to 1/5/05 revealed that the resident was ordered finger stick blood sugar and sliding scale insulin coverage twice a day at 6:30 A.M. and 4:30 PM. The resident's blood sugars from 1/1/05 to 1/5/05 were 91-136, requiring no insulin administration until the medication observation on 1/5/05 at 6:35 P.M., when the blood sugar was increased to 201. 5. According to Mosby's Drug Reference, the onset time for Novolin R insulin is 1/2 hour with a peak in 4-8 hours. The action of the Novolin R insulin is to decrease the blood sugar (glucose) by transporting insulin into the cells. The sliding scale Novolin R insulin is ordered to be given prior to mealtime at 4:30 P.M. in order for the onset of the action to occur while there is food in the digestive system. If the medication is given with no food in the system then there is the potential for the blood sugar level to become too low resulting in coma or death. wpuLusucu ree or cere Seren VIBULUN GAUL & RUOLIN According to Lippincott, Manual of Nursing Practice, the normal range of blood glucose levels is "60 to 110." “Accurate determination of capillary blood glucose (finger stick blood sugar) assists patients in the control and daily management of diabetes mellitus." "Blood glucose monitoring helps evaluate effectiveness of medication..." "Medication regimens and meal timing are considered to set the most effective monitoring schedule.” “Patients.,.may test (glucose levels) before meals and at bedtime.” The Lippincott manual states Regular Insulin added to the diabetic medication regimen assists with postprandial glucose control. Short-acting insulin (Novolin R) added in the morning controls glucose elevations after breakfast and "increased | blood glucose levels after supper can be controlled by the addition of short-acting 5 mn ; akfast and before supper provides 24- hour insulin coverage for diabetic residents, 6. A review of the facility's procedure for "Medication Administration-General Guidelines" reveals the nurse is to administer the medications "in accordance with written orders of the attending physician...and compliance with professional standards." "Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered Precisely as as ordered.” 7. In an interview with the LPN from the medication pass on Unit 2 on 1/5/05 at approximately 8:35 P.M., sho stated Unit 2 has 39 residents and the normal staffing is one nurse and 2-3 CNA The LPN stated she had just completed at 8:35 P.M. the administration of the medications ordered from 4:30 P.M. thru 6:00 P.M. She was taking a short break before resuming with the 9:00 P.M. medication pass.. The LPN states Unit 2 previously had a second nurse until “corporate” cut the nursing position. The LPN states the medication pass for Unit 2 is "horrible" "on a good night." The LPN states the nursing duties include medication pass, treatments, supervision of the CNAs, resident care, charting, dining duties and other duties. The LPN stops the medication pass at 5:20 P.M. to monitor the dining room on Unit 2 then resumes medication pass, 8. Observation of medication pass on 1/5/05 begining at 6:11 PM on Unit 100 revealed Resident #45's medication Glyburide 2.5-500 mg was ordered for 5:00 PM and was administered at 7:00 PM., this is a significant medication error. 9. During 2 medication pass observation on 1/5/05 at 7:30 P.M. the nurse was observed to crush the medications for resident #35. These meds were Lorazepam 0.5 mg and Prevacid 30 tog. These were then mixed with the liquid Calcium Carbonate 500 mg/5 mi and Carafate 1 gm/10 ml in approximately 60 cc of water and the medications were administered at one time to the resident via the Gastrostomy tube. The nurse stated, " I do not know how others do this but I mix all my meds together." The nurse did not flush the tube with 5 cc of water between each medication as ordered. Resident #35 has orders for "flush tube with 5 cc of water between each medication. There is an order to "check tube for proper placement prior to cach feeding/flush or medication administration." The nurse was observed to not check the gastrostomy tube for placement before administering the resident's medications. The gastrostomy tube was not flushed with 60 cc of water before the administration of the medications. The nurse did not elevate the resident’s head of bed 35-40 degrees before administering the medication. The medication administration record for resident #35 1/5/05 reveals no documentation of the following physician orders: i, Flush tube with 5 cc water between each med on the 7-3 and 3-11 shifts on 1/5/05. ii. Check for residual every 4 hours on the 7-3 and 3-11 shifts on 1/5/05. iii, Check tube for proper placement prior to each feeding/flush or medication administration on the 7-3 and 3-11] shifts on 1/5/05. iv. Change feeding spike cap set/bag every 3-11 was not documented as completed on 1/5/05. 10 WjULL/UZU se107040U4 OFrBUiUK GADUN & KUDEN vy. Flush tube with 30 ce water before and after each med pass was not documented for 7-3 shift 1/5/05. A review of the facility's policy "Enteral Tube Medication Administration" and "Enteral Tubes” reveals the procedure for administration of medication includes: - Resident is properly positioned (e.g. head of bed elevated at least 35-40 degrees) - Enteral feeding tube is checked for placement and patency prior to administration of medication. Verify tube placement by instilling 10-20 cc of air ito the tube while simultaneously avsculating over the left upper quadrant of the abdomen with a stethoscope to validate air movement in the stomach and aspirate 2-10 cc of gastric contents and re-install. -Tube is flushed with 30 cc water before and after all medications are administered. —— -Prepare liquid medications and mix with 20 cc of water. -Finely crush tablets and mix with 20 cc of water. The facility failed to follow its policy and Standards of Practice to prevent aspiration and complications of obstruction of the gastrostomy tube. ~ 10. During a medication pass observation on 1/5/05 beginning at 6:15 P.M. for Unit 2 (Hall 2) the following errors were noted im the timing of the administration of medications, which is over the 60 minutes as per the facility's policy and standard of practice. a. Resident #27-Singulair 10 milligrams (mg) and Risperdal 2 mg were administered at 6:15 P.M. The medication was ordered to be given at 5:00 P.M. b, Resident #22- Gemfibrozil 600 mg was ordered to be given 30 minutes before a meal and was given after the resident had eaten. The medication was scheduled to be given at 4:30 P.M. and was given at 6:30 P.M. c, Resident #22- Acidophilus was ordered at 5:00 P.M. and was given at 6:30 P.M. d. Resident #22- Metoclopramide (Reglan) was ordered to be given before meals at 4:30 P.M. and was given at 6:30 P.M. e. Resident #22- Calci-Mix is ordered given with meals or mix with food/applesauce. The medication was ordered for 5:00 P.M. and was administered at 6:30 P.M. approximately I hour after the resident ate dinner and the medication was not mixed with applesauce or food. f. Resident #28- Seroquel 100 mg is ordered at 5:00 P.M. and wes not given until approximately 6:40 P.M. g. Resident #29- Flexeril] 10 mg, Reglan 5 mg, and Docusate Sodium 100 mg were ordered to be given at 5:00 P.M. and were not given until approximately 6:43 P.M. h. Resident #30- Trazadone 50 mg, Geodon 20 mg, and Lortrel 5 mg/20 mg were ordered to be given at 5:00 P.M. and were not given until 6:45 P.M. i. Resident #31- medication Exelon 3 mg was ordered to be given at 5:00 P.M. and was not given until 7:00 P.M. ' j. Resident #26- medication titracet 37. 5/325, Ferrous Sulfate 325 mg, and Amaryl 2 mg was ordered to be given at 5:00 P.M. and were not given until 7:15 p.m. : k. Resident #35- Prevacid 30 mg was ordered to be given at 4:30 P.M. and was not given until 7:30 P.M. 1, Resident #35- Calcium Carbonate 500 mg/5 milliliters(ml) and Carafate 1 gm/10 ml were ordered to be given at 5:00 P.M. and was not given until 7:30 P.M. m Resident #35 was observed to be agitated, moaning "OH" and moving restlessly in bed. The resident's Lorazepam 0.5 mg (antianxiety medication) was ordered to be given at 5:00 P.M. and was not given until 7:30 P.M. The resident was unable to verbalize her needs. n. Resident #36- Bisacodyl 5 mg and Risperdal 0.5 mg were ordered to be given at 5:00 P.M. and were not given until 7:40 P.M. o. Resident #37- Lorazepam 1 mg, Neurotin 600 mg, Citracal with Vitamin D, and Lopressor 50 mg were ordered to be given at 5:00 P.M. and were not given until 8:20 P.M. p- Resident #38- Aricept 10 mg and Risperdal 0.5 mg were ordered to be given at 5:00 P.M. The resident's Remeron was ordered to be given at 6:00 P.M. All of the medications were administered at 8:30 P.M. 11 WyULles UL Ver ame eves gueat Poa peroovevuus Orereiun GAVUN & KRUDEIN WyUls/suzu 11, , — During the course of the observation of medication pass resident #26 was observed at 7:15 P.M. on 1/5/05 to complain of needing incontinence brief changed. The LPN stated for the resident to wait until the CNAs "made rounds.” The LPN was observed continuously from 7:15 P.M. until 7:45 P.M. and did not notify the CNAs of the resident's need for incontinence care. The resident was also observed to have a hoarse voice and a cough. The resident complained of a "cold." The resident stated she had cough and nasal drainage. The resident requested the nurse assess and intervene in the new condition. The nurse stated she had to complete medication pass and would follow up at a later time. The resident's sink was also noted to not be —~draining_ The sink was filled 4 with dirty water. The nurse stated she would have to complete a maintenance request but did not have time to address the problem. 12, During an observation of medication pass on 1/5/05 beginning at 6:11 PM on Unit 100 revealed the following errors in administration of medications within the I hour timeframe: - Resident #45's medication Glyburide 2.5-500 mg was ordered for 5:00 PM and was administered at 7:00 PM. . - Resident # 40's medications Clonidine 0.2 mg and Risperdal 0.5 mg were ordered to be given at 5:00 PM and were administered at 7:04 PM. - Resident # 41's medication Zanaflex 4 mg was ordered to be given at 5:00 PM and was administered at 7:25 PM. 13. Observation of medication pass on 1/6/05 begiming at 5:30 PM on Unit 200 revealed the following: ~ Resident #42 bad an order for Oyster Calcium with Vitamin D to be given At 5:00 PM, Oyster Calcium without Vitamin D was administered at 5:35 PM. - Resident #25's Reglan 5 mg was ordered to be given before meals at 4:30 PM and was given at 6:00 PM. . 14, A review of the treatment records for Unit 2 shows treatments are ordered to be completed by the nurse on each shift. The treatments are in addition to the medication pass and other duties. A review of these treatment records for Unit 2 from 1/1/05 thru 1/5/05 shows a lack of documentation for the following treatments. a, Resident #25 has orders for "A&D ointment to both heels (hard callous area) each shift) this treatment was not documented as completed on 7-3 shifts 1/1/05, 1/3/05, 1/4/05, and 1/5/05. The resident had orders for "Cleanse ulcer/abscess on left foot with dermal wound cleanser, apply wet to moist saline dressing, cover with dry gauze dressing twice a day." The treatment was not documented as completed on 1/4/05 for the 3-11 and 11-7 shift. b. Resident #35 has orders for "Ketoconazole 2% cream apply to myotic nail beds bilateral every evening.” The treatment was not documented as completed on 1/1/05, and 1/2/05 for the 3-11 shift. c. Resident #47 has orders for "cleanse open area to right buttock with normal saline apply thin layer accuzyme and dry dressing twice a day.” The treatment was not documented as completed on 1/1/05 for the 3-11 shift. a. Resident #48 has orders for "skin assessment weekly on Wednesday 3-11." The treatment was initialed as completed on 1/5/05 but a review of the weekly skin assessment sheet shows no documentation of a skin assessment on 1/5/05. The last skin assessment is 12/29/04. e. Resident #49 has orders for "skin assessment weekly on Tuesday 3-11." The treatment was not initialed as completed'on 1/4/05 and the last weekly skin assessment is documented on 12/21/04. : f, Resident #50 has orders for skin assessment weekly on Tuesday 3-11." The treatment is not initialed as completed and the last weekly skin assessment is documented on 12/28/04. g-Resident #51 has orders for "Ketoconazole 2% cream apply to areas on both feet twice daily..." The treatment is not documented as completed on 1/1/05 and 1/2/05. 12 Vao/sla/sZUUR LSIL5 FAA (2/896 40U4 SPECIURK GADUN & RUSEN {g7014/020 15. A review of the medication administration records for Unit 2 reveal the following missing documentation of medications and treatments for 1/1/05 to 1/5/05: a. Resident #52 has a gastrostomy tube and orders to "change syringe every 11-7." This is not documented as completed on 1/5/05. The tube is flushed with 100 cc of water every 4 hours. The orders “check tube for placement prior to each...flush..." is not documented as completed on 11-7 on 1/5/05. . b. Resident #53's medication administration record lists "Furosemide 40 mg daily” at 9:00 A.M. There is not documentation of this medication being administered 1/1/05 - 1/5/05. There is not documentation of this medication being held or discontinued. c. Resident #26 has orders for Alprazolam 0.25 mg at 6 AM, 2 P.M. and 10 P.M. There is not documentation of this medication being administeréd oii 1/5/05 at 2:00 P.M. . d. Resident # 35 has Levaquin 250 mg ordered everyday for 7 days. There is not documentation of this medication being administered on 1/3/05. e. Resident # 43 has orders for Risperdal 1 mg at 6 A.M. and 2 P.M. There is not documentation this medication was administered at 2 P.M. on 1/4/05 and 1/5/05. The resident also has Depakote DR 250 mg at 6 A.M., 2 P.M. and 10 P.M. There is no documentation this medication was given at 2:00 P.M. on 1/5/05. 16. A review of the treatment records for 1/1/05 to 1/5/05 of Unit 1 shows missed documentation of treatments. - Resident #54 -Nizoral 2% shampoo apply to hair/scalp on shower days twice weekly, Wednesday and Saturday. There is not documentation the treatment was completed on 1/5/05. + Resident #55- Nystatin & Triamcinolone Cream apply cream and put between folds twice daily. There is not documentation the treatment was completed on 7-3 shifts on 1/4/0S and 1/5/05. - Resident #34- Premarin Vaginal 0.625 mg/gm cream apply 1-fingertip Monday through Friday. There is not documentation the treatment was completed. on 3-11 shift on 1/4/05 and 1/5/05. . - Resident #56- Sodium Chloride 0.9% 500 ml irrigation, cleanse between 4° toe and little toe on right foot with NS apply TAO and cover with 4x4 or kling. There is no documentation of completion of this treatment on the 3-11 shift on 1/1/05 and 1/4/05. ~ Resident #57- Ammonium Lactate 12% Cream apply to palms of both hands at bedtime. There is no documentation of completion of this treatment on the 3-11 shift on 1/4/05. - Resident #17- Cleanse peg-tube site with soap and water every shift’ There is no documentation of completion of this treatment on the 3-11 shift on 1/4/05. - Resident # 58- Ammonium Lactate 12% lotion apply to lower extremities daily. There is not documentation of completion of this treatment on the 7-3 shift on 1/2/05. - Resident #59- Nystatin apply to buttocks/groin area twice daily, There is no documentation of completion of this treatment on the 3-11 shift on 1/2/05. The resident also has ordered Xenaderm-Cream apply to reddened area to lower inner buttocks every shift. There is not documentation of completion of this treatment on the 3-11 shift on 1/2/05 and 1/3/05. - Resident #60- TBC aerosol apply granulex to right hip and buttocks every shift and Granulex spray to scrotum every shift. This was not documented on the 7-3 and 3-11 shifts on 1/2/05. - Resident #15- cleanse all wounds with hibiclens pack with NSS wet to dry dressing ABD pad and cover with mefix three times daily. This was not documented on 7-3 shift on 1/2/05: and 3- 11 shift on 1/105 and 1/2/05. - Resident #16- Left heel bulky dry sterile dressing once a day. The treatment was not documented on 11-7 shift on 1/1/05, 1/2/05, and 1/4/05. Also, sodium chloride 0.9% irrigation solution mix with chlorpactin to left thigh, right hip and right groin twice a day. This treatment was not documented on 3-11 shift for 1/2/05. - Resident # 61- Ammonium Lactate 12% cream apply to both feet twice daily. This treatment is not documented as conipleted on 3-11 shift 1/2/05. ; - Resident # 62- Granulex Aerosol spray to right hip twice daily. This treatment is not documented as completed on 3-11 shift 1/2/05. : 13 Vos Las cuuy 10:60 FAA 14/09040U4 SrBULUK GAVUN & KUDSEN wWwuLosuzuU 17. An interview with LPN #2 (who works Unit 1 or Unit 2 on the 3-11 shift), on 1/5/05 at 2:00 P.M. and 1/6/05 at 8:50 P.M. he stated the med pass for the 5 P.M. medications on Unit 1 and Unit 2 is begun at 4:00 P.M. to 4:30 P.M. The LPN #2 stated the murse on Unit 1 and Unit 2 must stop medication pass at 5:20 P.M. and complete dining duties for approximately 1 hour. The 3-11 shift does not have a CNA to assist with dining duties and the nurse must stay until dining is completed. The medication pass is resumed after the dining snd the medications for 5 P.M. are administered after 6:20 P.M., which is over the allowed 1-hour timeframe for medication administration. The LPN #2 stated medication pass takes approximately 3-4 hours for 39 residents "interruptions, emergencies, admissions" dining and other duties. The combined —medication-passes-of 5:00 P.M.-and 9:00 P.M. takes until 10:30 P.M. for Unit 2. The LPN stated the Unit 1 has the same problem. The LPN stated often completes 5:00 P.M. medication pass at 7:00-7:30 P.M. on Unit 1. Unit 1 has 2 nurses on 3-11 shift, but one nurse is pulled for dining duties. The LPN stated he has reported the staffing and medication concems to the administrator without a resolution. 18. An interview with the Director of Nurses (DON) on 1/6/05 at 12:15 P.M., she stated the routine staffing of Unit 2 for the 3-11 shift is 1 nurse. The DON stated the facility had a second nurse for the unit but the position was cut because of corporate requirements for nursing staff. The DON stated the staffing cut was made approximately 2 months ago but could provide no documentation of a specific date. The DON stated the facility could not have the Unit - Managers and the extra nurse, so the extra nursing position for Unit 2 was deleted. The dining duties are covered by the Unit Managers on breakfast and lunch, but the 3-11 P.M. floor nurse covers the dining duties for their unit. The DON stated when the nursing staff was decreased; Hall 4 (which is a 26 bed unit) adjusted their treatment and medication times to accommodate the dining duties. The DON acknowledged she had considered making similar changes for the 200 hall on 3-11 shift, but had not followed up on this due to some resistance from a long time LPN floor nurse on the 200 hall who felt there may be other options. The DON stated she has not discussed any of these other options with the LPN, and no action has been taken to resolve the problem. The normal staffing for Unit 1 with 42 beds is 2 nurses on the 3-11 shift. One of the nurses on the 3-11 shift covers the evening dining duties in the main dining room. 19. An interview with the administrator on 1/6/05 at 12:30 P.M. repeated the information given by the DON on 1/6/05 at 12:15 P.M. The administrator denies anyone notifying her of problems with the completion of medication pass or other duties. The administrator further stated she had no idea that medication pass was taking so long on the 200 hall, and the first time . she was aware of a problem was on 1/5/05 when she stayed at the facility to observe medication pass with surveyors present. : This statement was a contradiction of the statements made by LPN #2, who stated he complained strongly to the Administrator about the time management problems with one nurse attempting to complete medication pass, dining duties, and other required duties on the 3-11 shift. He states he was plainly told the reason corporate had denied the extra nursing position was because of nurse staff cut backs 20. An observation of the medication pass on Unit 200 on 1/6/05 at 4:00 P.M. revealed the unit had been split into two sections with a medication cart for cach section, leaving two nurses to cover 39 residents, a duty normally assigned to one nurse. The medication pass began at 4:00 PM for one cart and 4:10 PM for the second cart. The pass was completed at 6:35 PM and 6:30 PM, respectively. Neither of the nurses doing medication pass were required to attend to dining room duty during this pass, a duty normally assigned to the medication nurse. The combined time for both nurses completing medication pass totaled 2 hours and 55 minutes, still outside the allowed parameters of a 2-hour medication pass. This time does not include the time, which would normally have been spent supervising dining, which would add approximately another hour to the overall time. . 14 21. In an interview with a Registered Nurse on 1/7/05 at 7:00 AM. she stated that the Unit 1 and Unit 2, 3-11 P_M. nurses must stop 5:00 P.M. medication pass at 5:20 for dining duties and then resume medication pass resulting in late medications. The Registered Nurse stated there was not a CNA to assist with the Dining Duties and the nurse must stay to the completion of the dining. She was concemed with the dining interrupting the medication pass. 22. During an observation on 1/4/05 of resident #4 the resident was observed in the bathroom unattended from 10:25 A.M. to 10:35 A.M. A review of the resident's current care plan stated the resident is at risk for falls related to "impaired cognitive skills, unsteady gait, arthritis, and incontinence.” Some of the interventions-listed included: "frequent checks on resident to assess for personal needs and safety and instruct CNA (Certified Nursing Assistant) to have resident in supervised areas when out of bed." During an interview with the Licensed Practical Nurse (LPN) on 1/5/05 at 11:45 A.M., he/she stated the resident is unable to use the call light in the bathroom and could provide no explanation for the resident being left unattended. 23. Review of the medical record for Resident # 1 revealed development of a facility acquired pressure sore on 11/01/04 with physician's orders for treatment beginning the same date. A second facility acquired pressure sore to the coccyx was documented on the Treatment Administration Record (TAR) with treatment initiated on 11/29/04. Review of the resident's care plans revealed no care plan to address these pressure sores was implemented until 12/9/04, over one month from the date the treatment began ‘on the first sore. 24. Review of the medical record for Resident # 9 revealed development of facility acquired pressure sores to both heels on 9/04/04 with physician's orders for treatment beginning the same date. The September 2004 TAR revealed another facility acquired pressure sore to the coccyx with treatment initiated on 9/14/04. Review of the resident's care plans revealed no care plan was initiated until 10/12/04; over one month from the date treatment began on the pressure sores to both heels. 25. An interview on 1/4/05 at 2:10 PM with the Director of Nursing (DON) confirmed neither care plan was initiated immediately after the resident's change in status. She stated the reason for this was probably due to the fact that both unit managers are new to their positions and had not been fully aware that it was their responsibility to update care plans. She stated they probably were not updated until the Assistant DON did a chart review and noticed the updates were needed, 26. Although treatment began to the pressure sores approximately one month prior to initiation of the care plans, the potential for harm existed and if nursing interventions identified in the care plans had been initiated sooner, it is likely the second pressure sotes may not have developed for cither resident. The administrator was notified of an Immediate Jeopardy situation at approximately 10:30 am CST on 01/06/2005. At approximately 1:30 pm on 01/07/2005, the administrator notified the survey team of the following corrective actions: an additional licensed practical nurse will be added to the Unit 2 hall to assist with medication pass; all mursing personnel will be re-inservice on medication pass procedures; and management staff will conduct quality assurance observations to ensure timeliness of medication administrations. 13. The deficiency was cited as a class I violation and AHCA mandated a correction date of February 6, 2005. A class I deficiency is: 15 vulaets euve Leeeo CAA $L107080U4 OrevuLuN GAVUN & KNUDSEN igQuUlsl/uzu a deficiency 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 harm, impairment, or death to a resident receiving care in the facility. he condition or practice constituting a class I violation shall be abated or elimimated immediately, unless a fixed period of time, as determined by the Agency, is required by correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency...[A] fine must be levied notwithstanding the correction of the deficiency. _§400. 423(8)(a) Fla. Stat. (2004) A conditional license may ‘be imposed upon the Respondent based upon the class I deficiency. Conditional licenses may be imposed as follows: A conditional license status means that the facility, due to the presence of one or more class I or class I deficiencies, or class II deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with the criteria established under this part or with the rules adopted by the agency. : §400.423(7)(b), Fla. Stat.(2004) 14. The above constitutes a violation of Fla. Admin. Code R. 59A-4.108(4) (2004), stating: The nursing home facility shall have sufficient nursing staff, on a 24-hour basis to provide nursing and related services to residents in order to maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility will staff, at a mininmm, an ‘average of 1.7 hours of certified nursing assistant and .6 hours of licensed nursing staff time for each resident during a 24 hour period. 15. The violation alleged herein constitutes a class I violation, and warrants imposition of a fine of $12,500.00 and imposition of a conditional license. COUNT I THE RESPONDENT FAILED TO ENSURE THAT THE FACILITY MAINTAINED SUFFICIENT. NURSING PERSONNEL TO MONITOR BLOOD GLUCOSE LEVELS OF INSULIN DEPENDENT DIABETIC RESIDENTS, FAILED TO ADMINISTER MEDICATIONS IN THE REQUIRED TIMEFRAME, AND FAILED TO INITIATE NURSING CAREPLAN INTERVENTIONS FOR PRESSURE SORES TIMELY; AND ’ THE CUMULATIVE EFFECT OF THESE SYSTEMIC PROBLEMS RESULTED IN THE FACILITY’S INABILITY TO ENSURE THE PROVISION OF QUALITY HEALTH CARE. 16 ver ater euve 40.49 FAA 1e1o704uU4e OrevuluN UAVUN & KUDEN jULlssuz0 Fla. Admin. Code Section 594-4.108(4)(2004) — §400.23(8)(a), Fla. Stat. (2004) §400.23(7)(b), Fla. Stat.(2004) §400.147(2), Fla. Stat. (2004) 42 CFR. §483.30(a)(1)&(2)(2004)-Nursing Services 16, AHCA realleges and incorporates paragraphs (1) through (5) as if fully set forth herein. “47. On or about January 7, 2005, AHCA conducted an annual survey at the Respondent’s facility. AHCA cited the facility based on the findings below, to wit: Based on observations, interviews, clinical record reviews and review of policies and procedures, it was determined that the governing body failed to ensure that the facility maintained sufficient nursing personnel to monitor blood ghicose levels of insulin dependent diabetic residents; failed to administer insulin per physician orders; failed to administer medications in the required timeframe and failed to initiate nursing careplan interventions for pressure sores timely. The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care. 18. The deficiency was cited as a class I violation and AHCA mandated a correction date of February 6, 2005. Class “II” violations are those conditions or practices related to the operation and maintenance of a facility or to the care of residents which the agency determines directly threaten the physical or emotional health, safety, or security of residents, other than class I violations. §400.423(8)0 Fla. Stat. (2004) ~-A conditional license may-be imposed upon the Respondent based upon the class I deficiency. Conditional licenses may be imposed as follows: A conditional license status means that the facility, due to the presence of one or more class I or class 0 deficiencies, or class If deficiencies not corrected within the time established by the agency, is not in substantial compliance at the time of the survey with the criteria established under this part or with the mules adopted by the agency. §400.423(7)(b), Fla. Stat.(2004) 17 ver agrees 40-49 PaA 1421 g0u40U4 SPBUivN uavuN &% RYuoLIT qyvagr ve 19. The above constitutes a violation of § 400.147(2), Florida Statutes (2004), stating: Internal risk management and quality assurance program.— Dd The intemal risk management and quality assurance program is the responsibility of the facility administrator. 20. The violation alleged herein constitutes a class II violation, and warrants a fine of $7,500.00 and the imposition of a conditional license. WHEREFORE, AHCA demands the following relief: 1, Entry of factual and legal findings as set forth in the allegations of this administrative complaint. 2. Imposition of fines in the amount of $35,000.00. 3. Imposition of a survey fee in the amount of $6,000.00. 4. Imposition of a conditional license NOTICE Respondent is notified that she has a right to request an administrative hearing pursuant to Fla. Stat. Section 120.57 (2004). 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 the Agency for Health Care Administration, Building 3, MSC #3, 2727 Mahan Drive, Tallahassee, Florida 32308; Agency Clerk. 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. 18 vos i4sZVU0 Loizy TAA f£/59040Ua SrBULUK GADUN & KUDEIN WUZUsS ZU Respectfully Submitted ais f day of March 2005 Leon County, Tallahassee, Florida. poe Fla. Bar. No. 540129 Counsel for Petitioner Agency for Healthcare Administration 2727 Mahan Drive Bldg. 3, MSC #3 Tallahassee, Florida 32308 (850) 921-0055 (office) (850) 921-0158 (fax) CERTIFICATE OF SERVICE I HEREBY CER’ that a true and correct copy of the foregoing has been served by certified mail on day of March 2005 to: Janet Aitken, Administrator, Bay Center, 1336 St. Andrews Boulevard, Panama City, FL 32405 and Spector Gadon & Rosen, P.A., Registered Agent, Hearthstone Senior Communities, Inc. Wb/a Bay Center, 360 Central Avenue, Suite 1559, St. Petersburg, FL 33701. 's L. Rosenthal, Esquire 19

Docket for Case No: 05-001311