STATE OF FLORIDA oP RR AGENCY FOR HEALTH CARE ADMINISTRATION mie STATE OF FLORIDA 7 AGENCY FOR HEALTH CARE ae ent ADMINISTRATION, Be VE Petitioner, vs. Case Nos. 2005001130 2005001535 CSAS24 DELTA HEALTH GROUP, INC., d/b/a LONGWOOD HEALTH CARE CENTER, Le Respondent. / oe ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Delta Health Group, Inc., d/b/a Longwood Health Care Center, (hereinafter “Respondent”), pursuant to §§ 120.569 and 120.57 Fla. Stat., (2004), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional, commencing 01/13/05 and ending 02/21/05, and to impose an administrative fine in the amount of $2,500.00 based upon Respondent being cited for one State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title 1V, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4, Respondent operates a 120-bed nursing home located at 1520 S. Grant Street, Longwood, Seminole County, Florida 32750, and is licensed as a skilled nursing facility under license number SNF12970961. 5. Atall times material hereto, Respondent was a licensed nursing facility under the licensing authority of the Agency and was required to comply with all applicable rules and statutes. COUNT I 6. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.25(c) and Fla. Admin. Code R. 59A-4.1288, based on the comprehensive assessment of a resident, the facility must ensure (1) that a resident who enters the facility without pressure sores does not develop pressure sores, unless the individual’s clinical condition demonstrates that they were unavoidable; and (2) a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. 8. On or about 01/10/05 through 01/13/05, Agency representatives conducted a survey at the Respondent nursing facility (hereinafter the “facility”. 9. Based upon observation, record review and staff interview, the Agency determined that Respondent failed to provide care and services to prevent pressure sores and to promote the healing of pressure sores for four of twenty-two sampled residents (Resident #2, #6, #9 and # 17). 10. Agency representatives reviewed Resident # 2's clinical records. 11. According to the clinical record, Resident # 2 was diagnosed with end-stage Alzheimer's disease, chronic eczema, and a history of weight loss. 12. Respondents staff documented on Resident # 2’s significant change Minimum Data Set (“MDS”) dated 11/11/04 that the resident was severely cognitively impaired, incontinent of bowel and bladder, non-ambulatory, and totally dependent on staff for activities of daily living (“ADLs”). 13. Review of the facility's Decubitus/Pressure Ulcer Risk Observation & Record indicated that residents with a score of 8 or above should be considered at risk for developing pressure ulcers/sores. 14. Respondent’s staff documented that Resident #2’s decubitus/pressure ulcer risk score totaled 17 on 07/20/04, 10/20/04 and 11/11/04. 15. Respondent’s Occupational Therapist Weekly Progress/Discharge Report dated 09/04 documented that the resident was on the caseload for seating and positioning due to multiple contractures and continued fetal position when in bed. 16. Several orthotic devices were initiated on 09/08/04 to be used with the resident. 17. Aknee flexion inhibitor bed positioning device was designed for the resident with the following instructions: use the device at least once a day when the resident is in bed, the device is to be worn as tolerated by the resident with no strict wearing schedule, and turn the resident with the device on. 18. Aright upper extremity functional hand splint was to be worn by the resident during the day for up to 8 hours or as tolerated by the resident and removed at night. We 19. A customized wheelchair device for trunk alignment was designed for the resident. The device consisted of a % lap tray with added right lateral support; a head rest with lateral pads for head/neck alignment; a coccyx scoop pummel wedge cushion for hip and leg alignment; and, bilateral foot supports with heel cut-outs to align ankles and decrease pressure on the heels. 20. Respondent’s staff documented on a Weekly Wound Information Sheet that the resident developed a Stage II pressure ulcer to the coccyx on 09/15/04 which measured 2.4 centimeters (cm) in length by 1.2 cm in width by 0.2 cm in depth with drainage noted and no odor noted. 21. On 09/24/04, Respondent’s staff documented on Resident # 2’s Weekly Wound Information Sheet that a Stage II pressure ulcer (on the coccyx) was identified which measured 2.4 cm in length by 1.4 cm in width. 22. On 10/07/04, Respondent’s staff documented on Resident # 2’s Weekly Wound Information Sheet that a Stage II pressure ulcer (on the coccyx) was identified which measured 1.2 cm in length by 1.1 cm in width. 23. On 10/15/04, Respondent’s staff documented on Resident # 2’s Weekly Wound Information Sheet that a stage 2 pressure ulcer (on the coccyx) was identified which measured 1.3 cm in length by 0.8 cm in width. 24. On 11/11/04, Respondent’s staff documented on Resident # 2’s Weekly Wound Information Sheet that a stage 2 pressure ulcer (on the coccyx) was identified which measured 1.7 cm. in length by 1.0 cm. in width. 25. On 12/28/04, Respondent’s staff documented on Resident # 2’s Weekly Wound Information Sheet that a stage 2 pressure ulcer (on the coccyx) was identified which measured 2.0 cm in Jength by 1.4 cm in width. 26. On 01/04/05, Respondent’s staff documented on Resident # 2’s Weekly Wound Information Sheet that a stage 2 pressure ulcer (on the coccyx) was identified which measured 2.4 cm in length by 1.8 em in width. 27, Resident # 2 had a Licensed Nurse Weekly Skin Observation Form on which Respondent’s nursing staff was to document at least once weekly, on the 3:00 p.m. to 1 1:00 p.m. shift, their observations of Resident # 2’s skin. 28. On 10/07/04, 10/14/04, 10/21/04 and 11/04/04, Respondent’s nursing staff failed to identify Resident # 2’s coccyx wound on the Licensed Nurse Weekly Skin Observation Form nor did they document a statement to see a treatment sheet for wound care. 29. On 10/29/04, Respondent’s staff documented on the Licensed Nurse Weekly Skin Observation Form that Resident’s # 2’s skin was "intact". 30. On 11/12/04, Respondent’s staff documented on the Licensed Nurse Weekly Skin Observation Form, “[n]o new area noted”. 31. On 01/11/05, during the survey visit, Agency representatives observed Resident # 2’s coccyx wound and noted three distinct clover leaf shaped wounds merging into one wound. Two of the wound beds were noted to be red/pale red in color and the third wound bed was noted to be green, yellow and beige in color. No odor was detected. 32. The treatment nurse was interviewed at that time and stated that the physician observed the wound on 01/10/05 and changed the treatment orders to include Panafil spray and covering the area with gauze twice daily until healed. 33. On 11/08/04, a Stage II pressure ulcer was found on the resident’s left buttock measuring 1.2 cm in length by 1.2 cm in width with no depth, odor or drainage noted. 34. A physician's telephone order dated 11/08/04 ordered staff to treat the wound (on the left buttock) with Granulex spray and apply Calmoseptic cream every shift, three times a day, until healed. The left buttock wound was noted as healed on 12/28/04. 35. On 12/28/04, Respondent’s staff documented on the Licensed Nurse Weekly Skin Observation Form that the left buttock would “had healed”. 36. On 11/10/04, Respondent’s staff documented on the Weekly Wound Information Sheet that an unstageable pressure ulcer was identified on the resident’s right ischial area measuring 4.2 cm in length by 3.7 cm in width. 37. Physician’s Orders dated 11/10/04 ordered staff to treat the Stage 1V (ischial) wound as follows: apply skin prep around the wound, apply Panafil spray to the area, and cover with Alldress twice a day. 38. Resident # 2’s clinical record contained a Nurse's Note entry dated 11/10/04 which stated the following: “A Stage [V wound found on resident right buttock [with] necrotic area in the center of wound. Wound is dry [without] drainage [with] measurement of L 4.2 W 3.7. Tx (treatment) order obtained, Tx done to area.” 39. Treatment Administration Records (“TAR’s”) for Resident # 2 dated 11/04 and 12/04 were reviewed. 40. According to the TAR’s, the onset of the unstageable right ischial wound was discovered on 11/07/04; however, the 11/04 TAR did not reflect any treatments until three days later on 11/10/04, Al. Review of the resident’s 11/04 “TAR” contained a signature indicating that treatment was performed on 11/10/04 on the 7:00 a.m. to 3:00 p.m. shift, but no signature was found on the 3:00 p.m. to 11:00 p.m. shift indicating that the treatment was not performed on that shift. Therefore, according to the clinical record, the treatment had not performed twice a day as ordered by the physician. 42. The resident’s Physical Therapy (“PT”) Initial Evaluation and Plan of Treatment sheet documented that the resident had “[a] right ischium unstageable ulcer that is necrotic and prevents patient from sitting OOB (out of bed) in w/c (wheelchair) for daily... activities." 43. The onset date of the ulcer was documented as 11/07/04, but PT evaluation and treatment did not start until 11/11/04, four days after the unstageable wound was first identified. 44. The right ischial wound was initially identified on 11/07/04. The left buttock wound was initially identified on 11/08/04 and an order was received for treatment on 11/08/04; however, no mention was made regarding the right ischial wound at the time when the order was received for the left buttock wound. 45. During the survey, on 01/11/05, Agency representatives interviewed the Director of Nursing (DON), the Dietician, the Administrator and the PT Assistant/Therapy Department Manager concerning Resident # 2’s pressure ulcers. 46. The PT assistant/Therapy Department Manager stated that she was informed of the resident's unstageable right ischial wound on 11/07/04 but was uncertain who informed her. 47. Review of the 11/11/04 PT Initial Evaluation and Plan of Treatment Form documented that the date of the onset of the pressure ulcer was 11/07/04. 48. The PT assistant/Therapy Department Manager stated the resident's right ischial/right buttock wound was observed and identified on 11/11/04 as follows: “Stage: unstageable; Drainage: slight to none; Size: 4.2 cm in length, 3.7 cm in width, no depth; Appearance: red edges, circular shape, black eschar covering approximately 90% of the center of the wound bed; Peri-wound tissue: pink, slightly macerated; Odor: none; Phase: absence of inflammation phase to chronic inflammation; Edges: distinct attached to necrotic tissue; Undermining/Tunneling: unable to determine but highly possible.” 49. The PT assistant/Therapy Department Manager further stated that the documented reason for the referral of the resident to PT was an unstageable right ischial ulcer that was necrotic and prevented the resident from sitting out of bed in his/her wheelchair for daily activities. 50. According to the therapy department’s documentation, the resident’s prior level of function related to goals established indicated that the resident was dependent for all care, had a modified wheelchair, and was free of open areas on the right ischium. 51. In the therapy department’s documentation under fall risk, the resident was identified as being fully dependent on staff for repositioning. 52. In the therapy department’s documentation under skin condition, the resident’s skin was identified as impaired with a Stage IV pressure ulcer. 53. Resident # 2 had a care plan addressing the resident’s skin and a care plan for a wheelchair orthotic device; however, these two care plans were not updated to reflect interventions initiated prior to or after the development of the pressure ulcers. 34. The facility failed to monitor and evaluate the resident's response to the use of the orthotic wheelchair device and failed to revise the approaches and/or interventions used after the resident developed the pressure ulcers. 55. On 11/12/04, Respondent’s staff documented on the resident’s at risk for skin breakdown care plan under interventions that the resident's position was to be changed every 2 hours. 56. No other evaluation of the wheelchair orthotic device or bed positioning device relating to the amount of time that the resident should sit upright in the wheelchair was documented. 57. The resident’s Physician Order Sheet for 12/04 and 01/05 contained the following order under rehabilitation (“rehab”) orders: "chair for positioning, check every 30 minutes, reposition every 2 hours”. 58. A “restorative bracing to the lower extremities” care plan dated 11/12/04 documented that restorative nursing applied braces to the resident as instructed and that the braces could be worn for up to 6 hours per day while the resident was up in the wheelchair. 59. On 01/10/04, Agency representatives interviewed the Director of Nursing (“DON”) who stated that “restorative bracing” referred to the wheelchair orthotic device. 60. On 01/10/04, Agency representatives interviewed the restorative nurse who stated that staff from the restorative department only performed range of motion to upper and lower extremities and applied the right hand splint. 61. According to the Dictician, who was also present during the interview, the resident had weight loss in 09/04, gained 7 pounds (Ibs.) in 11/04, and then the resident’s weight remained stable and within normal limits. 62. During the interview, the DON confirmed that staff did not document or measure the right ischial ulcer after it was identified on 11/07/04. 63. After this interview, on 01/11/05, the DON contacted two nurses who worked on 11/07/04 and obtained written documentation from them dated 01/11/05 regarding the pressure sore/ulcer. 64. The statements were presented to the surveyor team on 01/11/05 at 4:15 p.m. 65. Nurse # 1 wrote the following statement for 11/07/04 at 3:00 p.m.: "a certified nursing assistant reported the resident had an open area on the right buttock, writer observed a “stage 3” wound with dark edges. Area cleansed with normal saline, applied calmoseptic as per facility protocol. Treatment nurse wrote a request in the attending physician's book to check wound the next day (Monday) and evaluate for a treatment order.” 66. Nurse # 2 wrote an entry for 11/07/04 at 3:00 a.m. and for 11/09/04 at 3:00 a.m. The nurse documented, "resident was sprayed with granulex and calmoseptic ointment applied to right buttocks and coccyx to help area to heal". 67. Nurse # 2 was interviewed on 01/11/05 at 4:25 p.m. The nurse stated that the right ischium was a Stage II on 11/07/04. 68. Nurse # 2 confirmed that she did not measure the wound, document any observations concerning wound or contact the physician. 69. Nurse #2 further stated that she used the same treatment "pink stuff", calmoseptic cream and granulex, on the right buttock that she applied to the left buttock per standing order. She stated that the left buttock “looked good and almost healed”. 70. According to the Weekly Wound Information Sheet, the left buttock wound was not identified until 11/08/04. 71. The DON stated, “[t]he attending physician's standing orders were used by these two nurses”. 72. The DON was questioned regarding what preventative pressure ulcer measures were implemented by staff prior to the resident’s development of the 11/07/04 ischial wound. 73. The DON stated that dietary was involved and that the resident was placed on an air mattress; however, positioning and duration of time in the wheelchair was not addressed by staff. 74. The Attending Physician's Routine Admission Order's Sheet (no date documented) was reviewed. The Physician’s Routine Admission Order Sheet contained the following orders for Stage | and/or excoriated skin: “[a]pply xenaderm twice a day with each incontinence product change and as needed or four times a day and as needed if continent." 75. The Physician’s Routine Admission Order Sheet further instructed staff to call the physician regarding pressure ulcers if no treatment protocol was available and/or ordered. 76. According to the orders, the physician was to be called at regular hours if a new onset pressure ulcer was treated with the protocol. 77. A Physician's Telephone Order (“TO”) for PT treatment dated 11/11/04 documented the following orders: (1) "Physical therapist to eval and treat as necessary. Therapy 5 x a week for 4 weeks, for hydrospray to right ischium, wound management, ultrasound to the ulcer, therapeutic activities and exercises"; and (2) “Physical therapist to apply panafil, skin prep and all-dress dressing to right ischium ulcer after ultrasound and hydrospray during the 7 am-3 pm shift, Monday, Tuesday, Wednesday, Thursday and F: riday. Nursing to apply dressing on second shift Monday thru Friday and twice on Saturday and Sunday.” 78. Review of the therapist's first treatment note on 11/11/04 indicated that ultrasound was performed on the wound for 5 minutes, hydrospray was not performed, the wound was treated with Panafil, and an All-dress dressing was applied. 79, On 11/12/04, no ultrasound treatment was rendered. The following was documented, "the right ischial wound was debrided and packed with Dakin's solution and covered with abd pad and taped”. 80. No order was found for the Dakin's solution packing. 81. Review of the clinical record for 11/15/04 to 12/17/04 indicated that during this period no ultrasound treatments were performed and no specific medicated treatments were applied to the resident except for the application of dressings. 82. According to AHCPR’s Clinical Practice Guideline # 15 for Treatment of Pressure Ulcers 6-7 (1994), the following guidelines should be followed regarding managing tissue loads and ulcer care: "Interface pressure may be particularly high over sitting surfaces. When a pressure ulcer has formed on such a surface, the individual should avoid sitting. If pressure on the ulcer can be totally relieved, the person can sit for a limited time. Proper postural alignment, distribution of weight, balance, stability, and continuous pressure relief are important positioning considerations for the sitting individual. A written plan for the usc of positioning devices should be developed and implemented"; and, "Antiseptic agents (e.g., povidone iodine . . . sodium hypochlorite solution [Dakin's solution] . . . and skin cleansers are toxic to wound tissue and should not be used." 83. On 01/12/04, during interview with the DON, the DON stated that Resident #2 remained in bed and was not up in the wheelchair. 84. The DON was informed that the resident was observed sitting in the wheelchair on 01/11/05 at 9:15 a.m. 85. The DON confirmed that the Weekly Skin Observation Forms were not accurate. 86. Agency representatives observed Resident # 2’s right ischial pressure sore/ulcer and found the condition of the would to be as follows: The wound was odorous, draining a moderate amount of grayish yellow exudate and measured 6.0 cm in length by 4.2 cm in width by 4.6 cm in depth with undermining measuring 1.1. cm at 12:00 o'clock, 1.6 cm at 3:00 o’clock, 1.0 cm at 6:00 o'clock, and unable to measure at 9:00 o'clock due to blackish/grey moist necrotic tissue in the wound bed. 87. Discrepancies were found to exist between the physical therapy orders, nursing orders and treatments rendered. 88. On 11/12/04, a Physician’s Telephone Order directed nursing to use a Duoderm occlusive dressing and change the dressing every 3rd day and as needed. 89. The occlusive dressing was changed and reapplied on 11/1 5/04 on the 7:00 a.m. to 3:00 p.m. shift, and the resident was treated by therapy on the same day with Panafil. 90. On 11/16/04, a Physician’s Telephone Order indicated to irrigate the wound with Dakin's solution and pack the wound lightly with Nugauze daily. 91. No nursing treatment was done on 11/19/04 and therapy continued to treat the resident with Panafil. 92, On 11/22/04, a Physician’s Telephone Order indicated to treat with Accuzyme packing daily and for therapy to continue with Panafil. 93. No nursing treatment was rendered on 11/28/04. 94. The resident developed a urinary tract infection and wound infection and was treated with two antibiotics initiated on 11/28/04 and 11/29/04. 95. During interview on 01/11/05, the administrative staff indicated that a culture of the wound was never obtained. 96. On 11/29/04, a Physician's Telephone Order instructed to increase the Accuzyme packing to twice a day and for therapy to treat with Panafil. 97. On 12/14/04 at 6:00 p.m., a Physician's Telephone Order indicated to use Panafil and Nugauze packing twice a day. 98. No nursing treatments were rendered on 12/14/04 on the 3:00 p.m. to 11:00 p.m. shift, on 12/15/04 on the 7:00 a.m. to 3:00 p.m. shift, and on any shift on 12/16/04. 99. Therapy services were discontinued on 12/17/04. 100. A Physician's Telephone Order dated 12/27/04 indicated to use Dakin's solution on gauze packed into the wound and covered with a dressing twice a day for 4 days, then use Accuzyme on Nugauze packed into the wound twice a day. 101. Review of the TAR revealed the Panafil treatment with Nugauze packing continued twice a day until 12/31/04, along with Dakin's solution packing twice a day. 102. | Review of the TAR revealed wound treatments with Accuzyme were not done on (1/03/05 on the 3:00 p.m. to 11:00 p.m. shift and on (01/07/05 on the 7:00 a.m. to 3:00 p.m. shift. 103. On 01/08/05, a Physician's Telephone Order indicated to treat the wound with Dakin's solution packing twice a day. 104. Review of the 01/05 TAR revealed treatments were not rendered on 01/08/05 and (01/09/05 on the 7:00 a.m. to 3:00 p.m. shift. 105. On 01/13/05, Agency representatives interviewed the physical therapy department manager and a physical therapist. 106. The physical therapy department manager stated that she was unaware that different treatment orders were received from the physician and that nursing was carrying out the orders and rendered care twice a day. 107. She confirmed that there was no communication between the therapy department and nursing pertaining to the resident's wound and treatments. 108. She confirmed that a physician’s order was not obtained for the Dakin's solution treatment rendered on 11/12/04, that the ultrasound treatments had not been documented, that the specific Panafil treatment was not identified on the daily wound treatment sheets, and that no therapy treatments were rendered on 11/25/04, 11/26/04 and 11/30/04. 109. A Nurse’s Note dated 11/22/04 at 2:00 a.m. documented that the resident was out of bed during the day in a wheelchair and was fed his/her meals. 110. A Nurse’s Note dated 12/02/04 at 2:00 p.m. documented that the resident was out of bed to a chair with assistance and transferred to the activities room. 111. A Nurse's Note dated 12/06/04 at 3:15 p.m. documented that the resident was out of bed in a chair and returned back to bed after lunch. 112. On 12/22/04, the 11:00 p.m. to 7:00 a.m. Nurse’s Note entry documented that the resident was out of bed in a wheelchair with assistance from staff. 113. Agency representatives interviewed the occupational therapist on 01/12/05 to determine if the appropriateness of the wheelchair orthotic device for the resident was reviewed periodically. 114. According to the occupational therapist, the therapist evaluated the device and checked the resident's skin integrity on 09/08/04 and on 10/31/04, found no issues, recommended continue use of the device, and did not develop a seating schedule. 115. The pummel cushion design was discussed with the therapist. The therapist stated that when the resident was sitting on the cushion, the majority of the resident's weight was placed on the bilateral ischials. 116. The therapist was then informed that the resident developed pressure ulcers on the coccyx 09/15/04, the left buttock on 11/08/04, and the right ischial on | 1/07/04. 117. The therapist was asked for documentation of the skin integrity checks, if the appropriateness of the device was re-evaluated, and ifa resident specific seating schedule was developed. 118. She stated that no skin integrity documentation was completed, no re-evaluation of the device was performed, and that no specific seating schedule was developed for the resident other than changing the resident's position every 2 hours to relieve pressure. 119. Review of the 12/04 and 01/05 Physician's Order Sheet, under rehabilitation (“rehab”) orders, identified the following: "[c]hair for positioning check every 30 minutes, reposition every 2 hours. Do ADL's (activities of daily living) for 10 minutes and reposition every shift.” 120. Another physician’s order for a Broda chair was identified which stated, “Broda chair for positioning, comfort, check every 30 minutes, reposition every 2 hours. Do ADL’s for 10 minutes and reposition.” 121. A physician's telephone order dated 12/02/04 documented a physician’s order that the resident was to be out of bed in the wheelchair for 1-2 hours a day and placed back into bed until his/her wound was healed. 122. The resident was observed in the enhanced dining/activities room sitting in a wheelchair on 01/11/05 at 9:15 a.m. participating in ball toss activities and on 01/13/05 at 8:30 a.m. being fed by a Certified Nursing Assistant (CNA). 123. The resident was observed in bed on 01/1 1/05 at 12:25 p.m. with the head of the bed at an approximate 75-80 degree angle being fed by a nursing assistant. 124. Review of the certified nursing assistant (CNA) care plan for the resident, found in the Activities of Daily Living (“ADL”) Flow Record Book, identified under the mobility section that a Broda chair was to be used. 125. No evidence of the 12/02/04 physician’s order, which ordered staff to limit the amount of time the resident was to sit in the wheelchair, was reflected on the care plan or ADL flow sheets. 126. The DON was interviewed on 01/12/05. She confirmed the aforementioned findings concerning the failure of staff to document the physician’s order on the resident’s care plan or ADL flow sheets. She further stated that she communicated the 12/02/04 physician’s order by placing a memo in the ADL flow sheet book; however, she was unable to locate and/or produce any such memos. 127. The activities director was interviewed on 01/12/05. She stated that the resident had participated daily in the enhanced dinning room program for breakfast and lunch and the enhanced activities program since (1/20/04. 128. The enhanced dining room/activities CNA was interviewed on 01/13/05. 129. The CNA stated that during 9/04, 10/04, 11/04 and 12/04, when she arrived at work, the resident would be in the enhanced dining room at 7:00 a.m. or 8:00 a.m. daily. The resident would be fed breakfast and lunch by the staff and remained up for activities until the resident was returned to bed at around 1:00 p.m. daily. 130. The CNA stated that every two hours she would stand the resident for five (5) minutes and sit him/her back down into the wheelchair. 131. She confirmed the resident was up for breakfast on 01/10/05 at 8:00 a.m., on 01/11/05 at 8:00 a.m., and on 01/13/05 at 8:30 a.m. 132. She stated that currently the resident was up for only 1-2 hours a day for breakfast and activities and then returned to bed. 133. When asked when the change was initiated, she stated the last week of 12/04 and beginning of 01/05. 134. The DON, corporate nurse consultant, therapy department manager and physician's assistant (PA) were interviewed on 01/13/05. 135. The PA confirmed the following: the right ischium skin integrity, prior to the development of the 11/07/04 Stage IV, unstageable, eschar covered wound, would have been identified by an area of reddened/purplish color skin with distinct edges; the physician's standing order for a Stage I/excoriation was Xenaderm and not Calmoseptic cream and Granulex; and, the physician should have been contacted on 11/07/04 when the unstageable wound was identified. During a physician's visit on 11/22/04, the wounds were not identified or assessed. 136. Respondent’s corporate nurse consultant confirmed that the initial treatment to the right ischium was untimely and delayed and that no assessment was documented when the wound was found. 137. During interview with the therapy manager, the manager was asked if the resident's sitting time in the wheelchair, repositioning time in bed and in the wheelchair, and bed orthotic devices were considered and re-evaluated prior to the onset of pressure ulcers and at the time pressure ulcers were found. The therapy manager stated that the resident was repositioned more often; however, no documentation was completed and no evidence of more frequent repositioning was presented. 138. The facility administration was asked why a resident with a Stage IV right ischial pressure ulcer continued to sit in the wheelchair for 1-2 hours a day without re-assessment. 139. The DON responded that the resident ate better sitting up than being fed in bed. 140. Resident # 6 was re-admitted to the facility on 09/24/04 after sustaining a hip fracture. 141. His/her diagnoses include: right hip fracture, urinary tract infection, Alzheimer’s Disease/Dementia, hyperglycemia and history of ischemic cerebrovascular accident. 142. During the initial tour of the facility on 01/10/04 with a nurse on the B-wing, it was revealed that the resident had a Stage IV house-acquired pressure sore. 143. According to documentation found in the clinical record in the Nurses’ Notes, the pressure sore was first identified on 11/18/04. 144. The documentation stated, "resident has “unassuageable” (unstageable) wound to right buttocks necrotic”, 145. According to the resident’s care plan for skin breakdown, dated 10/14/04, skin checks were to be performed by CNA’s during showers and any areas of skin breakdown were to be reported to the nurse. Also, weekly skin checks were to be done. 146. Review of the weekly skin checks revealed that they were not consistently being performed. Staff did not document that skin checks were performed on 10/ 19/04, 10/26/04 and 11/2/04. 147. During the same time that the skin checks were not being documented, the resident had a Stage II pressure sore to his/her coccyx that the facility was providing treatment to and was found to be healed on 11/30/04. 148. During an interview on 01/12/04 with the nurses on the B wing, the nurse that was called into the room by the CNA who discovered the pressure sore verified that the pressure sore was unstageable on 11/18/04. 149. Documentation on the Weekly Wound Information Sheet dated 11/20/04 described the area as 3 cm by 3 cm having necrotic tissue. 150. A physician’s order was received on 11/22/04 for staff to use Accuzyme spray to the area twice a day (“BID”). 151. Another physician’s order was received on 12/02/04 to use Normal Saline and Hydrospray as medically needed to debride the right ischium. 152. Review of the resident’s Treatment Records revealed that staff failed to document that the resident received the ordered treatment on 11/24/04,11/28/04, 12/01/04, 12/02/04, 12/03/04 12/05/04, 12/07/04, 12/08/04 and 12/09/04. 153. On 12/27/04, a new treatment order was received for “Dakins 2 strength 4 Sol. pat dry and pack 2 x 2's in Dakins and then apply dry sterile dressing (DSD) BID”. 154. On 01/03/05, the physician ordered a Wound VAC for the area. 155. The resident was observed by Agency representatives to be in bed the four days of the survey. 156. The resident would not respond when you called his/her name or tried to speak to him/her. 157. The current wound measurements were 1.5 cm by 1.2 cm with a depth of 4.0 cm. 158. The area continued to be a Stage IV pressure sore according to documentation on the 01/05 pressure ulcer report. 159. The wound was not observed due to the resident having a Wound VAC to the 20 area. 160. The nurse attempted to observe the wound on 01/13/04 when the resident had pulled the Wound VAC off. However, the black foam was securely attached to the area. 161. During an interview on 01/13/04 with the facility administrator, the DON, and the attending physician’s Advanced Registered Nurse Practitioner (ARNP), the facility confirmed that the area was not found until 11/18/04 when the wound was unstageable with necrotic tissue. 162. Resident # 9 was re-admitted from the hospital on 01/06/05. 163. Review of the resident’s 10/18/04 Decubitus/Pressure Ulcer Risk Observation & Record identified that the resident had a total score of 14 placing him/her at risk for pressure ulcer development. 164. Review of the 01/06/05 Resident Admission-Data Collection Form and a Nurses’ Note dated 01/06/05 at 10:00 p.m. identified that the resident had a red small area on the right inner foot. 165. A Physician's Progress Note dated 01/10/05 identified that the resident was at risk for skin issues. 166. Review of the residents 01/05 TAR revealed a physician’s order dated 05/27/04 for bilateral heel protectors on at all times. 167. The resident’s "At Risk for Skin Breakdown" care plan dated 10/18/04 identified that bilateral heel protectors were to be used. 168. On 01/11/05, Agency representatives observed the resident's skin integrity with the treatment nurse. 21 169. Agency representatives observed that the tissue on top of the resident's calcaneum bone on the right inner foot was red, Stage J, and approximated to measure 1.0 cm in length by 0.3 cm in width. 170. The resident was not wearing heel protectors. 171. The treatment nurse was interviewed and confirmed that heel protectors were not on the resident. 172. No documented evidence was found that staff had performed assessments of the pressure ulcer since it was identified on 01/06/05. 173. No treatment order was found and no measurement of the Stage I pressure ulcer was documented on the Weekly Wound Information Sheet. 174. On 01/12/05, Agency representatives observed the resident in the resident’s room with the unit nurse manager and the DON and found the resident's right inner foot with a reddened area. 175. The unit nurse manager confirmed that the reddened area was a Stage I pressure ulcer and both confirmed the above findings. 176. Resident # 17 was assessed to be at risk for pressure sores. 177. According to the resident’s plan of care, weekly skin checks were to be conducted. 178. Review of the resident’s 09/04 TAR indicated that the resident was to receive skin prep to the right heel every shift. 179. Further review of the 09/04 TAR revealed that this treatment was missed seven times. 180. Also, two of five weekly skin checks were not documented in 09/04. 22 181. On 10/07/04, a weekly skin check indicated that the resident's skin was clear and intact; therefore, no pressure sores were identified. 182. The resident was to have weekly skin checks on 10/14, 10/21 and 10/28, but there was no evidence that these skin checks were performed. 183. According to the resident’s 10/04 TAR, the resident did not receive nine skin prep treatments to the right heel. 184. The resident acquired unstagable pressure sores to the right and left heels on 10/30/04. 185. On 10/30/04, new physician’s orders were received for both heels to be cleansed with Normal Saline than sprayed with Granulex every day on the 7:00 a.m. to 3:00 p.m. shift. 186. According to the resident’s 11/04 TAR, the resident did not receive the ordered treatment seven times for that month. 187. On 11/11/04, the weekly skin check indicated that the resident's skin was intact with no open areas; however, the weekly skin check dated 11/25/04 indicated that the right heel was necrotic and that Granulex spray was being used daily. 188. Weekly skin checks were not documented as being performed two times in the month of 12/04; 12/23/04 and 12/30/04, respectively. 189. On 12/09/04, the treatment orders changed with orders to clean the resident’s bilateral heels with Normal Saline, spray with Granulex, and keep open to air until healed. In addition, skin prep was to be applied to the right heel as needed (PRN). 190. According to the resident’s 12/04 and 01/05 TAR’s, skin prep had not been used on the resident’s right heel since 12/09/04. 191. The Agency has determined based upon the aforementioned findings that 23 Respondent failed to provide necessary care, treatment and services to prevent pressure sores and/or to promote healing, prevent infection and prevent new sores from developing for Resident # 2, Resident # 6, Resident # 9, and Resident # 17 in violation of 42 CFR § 483.25(c) and Fla. Admin. Code R. 59A-4.1288. 192. The Agency determined that this deficient practice compromised the residents’ ability to maintain or reach their highest practicable physical, mental, and psychosocial well- being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services, and cited this deficient practice as a isolated State Class II deficiency. 193. The Agency provided Respondent with a mandatory correction date for this deficient practice of 02/03/05. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(b) and 400.102, Fla. Stat. (2004), and assess costs related to the investigation and prosecution of this case, pursuant to § 400.121(10), Fla. Stat. (2004) COUNT I 194. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and paragraphs seven (7) through one hundred ninety-three (193) as if fully set forth herein. 195. Based upon Respondent’s cited State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(b), Fla. Stat. (2004). WHEREFORE, the Agency intends to assign a conditional licensure status to 24 Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7)(b), Fla. Stat. (2004), commencing 01/13/05 and ending 02/21/05. / Respectfully submitted this vy day of March 2005. fink deans ma Tiana Fla. Bar. No. 571628 Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 727.552.1435 (office) 727.552.1440 (fax) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2004), Respondent shall post the most current 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. Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the attention of: The Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. The Remainder of This Page Intentionally Left Blank 25 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by Certified Mail, Return Receipt No: 7003 1010 0002 4667 1576 on March Daud cos to: Glen Anthony Miller, Administrator, Longwood Health Care Center, 1520 S. Grant Street, Longwood, Florida 32750 and U.S. Mail to: Sondra McCrory, Registered Agent, Longwood Health Care Center, 2 North Palafox Street, Pensacola, Florida 32502. Humbe mM VY rt) Ktmberly™. Murray, Esqire Copies furnished to: Glen Anthony Miller Sondra McCrory Kimberly M. Murray Administrator Registered Agent Senior Attorney Longwood Health Care Center | Longwood Health Care Ctr. Agency for Health Care 1520 S. Grant Street 2 North Palafox Street Administration Longwood, Florida 32750 Pensacola, Florida 32502 §25 Mirror Lake Drive, 330D (U.S. Certified Mail) (U.S. Mail) St. Petersburg, Florida 33701 (Interoffice) 26 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. 2005001130 Longwood Health Care Center 2005001535 Facility Name AHCA Case No.

Docket for Case No: 05-001525