STATE OF FLORIDA ep os, AGENCY FOR HEALTH CARE ADMINISTRATION b, a . > we op STATE OF FLORIDA he Oo, AGENCY FOR HEALTH CARE “Le ey Pe ADMINISTRATION, om ° Petitioner, vs. Case Nos. 2005003038 2005002275 THE PARKS HEALTH CARE ASSOCIATES, LLC, d/b/a PARKS HEALTHCARE AND _ _ REHABILITATION CENTER, a 5 “2 | SS Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against The Parks Health Care Associates, LLC, d/b/a Parks Healthcare and Rehabilitation 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 02/25/05 and ending 03/10/05, and to impose an administrative fine in the amount of $5,000.00 based upon Respondent being cited for two State Class Il deficiencies. 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 ween 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 IT, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Respondent operates a 120-bed nursing home located at 9311 S. Orange Blossom Trail, Orlando, Florida 32837, and is licensed as a skilled nursing facility under license number SNF1089096. 5. At all 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 Florida law, a facility must immediately inform the resident; consult with the resident’s physician; and if known, notify the resident’s legal representative or an interested family member when there is — (A) an accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident’s physical, mental, or psychosocial status (.e., a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (i.e., a need to a discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment)...42 CFR § 483.10(b)(11) and Fla. Admin. Code R. 59A-4.1288 (2004). 8. On or about 02/24/05 through 02/25/05, the Agency conducted a complaint survey (CCR # 2005001303) at the Respondent nursing facility. ed 9. Based upon record review and staff interviews, the Agency determined that the Respondent facility failed to immediately notify a resident's physician and family member of a significant change in the resident's physical condition. Said failure to notify the resident’s physician resulted in the resident’s failure to improve and deterioration of the resident’s condition. 10. Resident # 1 was admitted to the Respondent facility on 01/28/05 from a local hospital with diagnoses of pneumonia organis, chronic airway obstruction, chronic obstructive airway disease, congestive heart failure and a history of diabetes Type Il. 11. Review of the resident's transfer and continuity of care document form (Form 3008) from the hospital, dated 01/28/05, reflected that the resident entered the facility with orders for respiratory/pulmonary (lung) medications and breathing treatments. 12. The resident was also admitted with physician’s orders for 2 liters of oxygen via nasal cannula to be given at night and as necessary (“PRN”) during the day. The physician’s order required that nursing staff maintain the resident's oxygen saturation levels above 90%. 13, On 02/24/05, Agency representatives performed a record review of the facility’s nurse’s notes for Resident # 1. 14. A nurse’s note dated 02/04/05 at 5:00 p.m. documented that the resident exhibited labored respirations with chest congestion and that the resident was unable to cough up any mucous. 15. The nurse documented that the resident had an oxygen saturation level of 84%. 16. According to the nurse’s note, the resident’s nasal cannula was changed to an oxygen mask to aid in breathing and a breathing treatment was administered which raised the resident’s oxygen saturation level to 90%. 17. The Respondent facility failed to have any documentation in the resident’s records to indicate that the resident's physician was notified of the resident's breathing difficulties nor the need to change the resident’s nasal cannula to an oxygen mask. 18. At 5:30 p.m. on 02/04/05, the resident's family was in attendance at the facility. According to the resident’s nurse’s notes, the resident kept removing the oxygen mask from his/her face and the resident’s family removed the oxygen mask and re-applied the nasal cannula. 19. Staff failed to determine the resident’s oxygen saturation level after the change and/or removal of the respiratory apparatus which was being used to supply oxygen to the resident. 20. In addition, the resident’s record still failed to indicate that the resident’s physician was contacted regarding the resident’s condition. 21. On 02/05/05, at approximately 12:00 a.m., staff documented in Resident # 1°s nurse’s notes that the resident continued to have labored respirations with chest congestion. 22. The resident’s oxygen saturation level was documented as 82% with the oxygen mask in place. 23. The record still failed to indicate that the resident’s physician or family was contacted regarding the resident's condition. 24, On 02/05/05 at 2:35 a.m., the resident was found unresponsive with an absence of vital signs. Cardio-pulmonary resuscitation was initiated and the paramedics were called; however, the paramedics were unsuccessful in resuscitating the resident. 25. Agency representatives conducted an interview with the resident's physician on (02/24/05 at 2:00 p.m. The resident’s physician stated that he/she would have expected nursing staff on duty to notify him/her by phone that the resident’s oxygen saturation was below 85%. However, the physician stated that he/she was not notified. 26. The resident's physician further stated that he/she was “perplexed that this situation had gone unreported to him/her.” 27. On 02/24/05, Agency representatives reviewed the facility's policy and procedure manual which was dated July 1998. 28. A policy and procedure addressing respiratory care and pulse oximetry stated that oxygen saturation levels are to be monitored every two (2) hours and that the physician was to be notified immediately if results of testing are outside of expected ranges or as a patient's clinical condition indicates. 29. According to the resident's care plan, dated 01/28/05, for recurrence of respiratory problems, staff were required to assess the resident’s respiratory system and monitor the resident’s oxygen saturation levels. 30. | The Agency determined that Respondent had not provided the necessary care and services and had compromised the resident's ability to maintain or reach his or her 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 an isolated State Class II deficiency. The Agency is authorized to impose a fine in the amount of two thousand five hundred dollars ($2,500) for an isolated State Class II deficiency. 31. The Agency provided Respondent with a mandatory correction date for this deficient practice of 03/04/05. WHEREFORE, the Agency intends to impose an administrative fine in the amount of wn $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 It 32. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) as if fully set forth herein. 33. Pursuant to Florida law, the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following — (i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well being ...42 CFR § 483.20(k)(1) and Fla. Admin. Code R. 59A-4.1288 34. Pursuant to Florida law, the services provided or arranged by the facility must meet professional standards of quality. 42 CFR § 483.20(k)(3)(i) and Fla. Admin. Code R. 59A- 4.1288 35. Florida’s “Nurse Practice Act” defines the “practice of professional nursing” as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others; (2) The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments, and; (3) The supervision and teaching of other personnel in the theory and performance of any of the above acts. § 464.003 (3){a), Fla. Stat. (2004). 36. Florida’s “Nurse Practice Act” defines the “practice of practical nursing” as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse...... The professional nurse and practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing. § 464.003 (3)(b), Fla. Stat. (2004). 37. On or about 02/24/05 through 02/25/05, the Agency conducted a complaint survey (CCR # 2005001303) at the Respondent nursing facility. 38. Based upon observation, staff interview and record review, the Respondent facility failed to ensure that nursing staff members provided services that meet professional standards of quality by failing to follow physician's orders, by failing to appropriately monitor and assess residents’ conditions, and by failing to contact a physician to report changes in resident conditions for two of seventeen sampled residents (Resident # 1 and Resident # 4). 39. Resident # 1 was admitted to the Respondent facility on 01/28/05 from a local hospital with diagnoses of pneumonia organis, chronic obstructive pulmonary disease, chronic airway obstruction, congestive heart failure, and a history of diabetes Type II. 40. Review of the resident's transfer and continuity of care document form (Form 3008) from the hospital, dated 01/28/05, reflected that the resident entered the facility with orders for respiratory/pulmonary (lung) medications and breathing treatments. 4}. The resident was also admitted with physician’s orders for 2 liters of oxygen via nasal cannula to be given at night and as necessary (“PRN”) during the day. The physician’s order required that nursing staff maintain the resident's oxygen saturation levels above 90%. 42. On 02/24/05, Agency representatives performed a record review of the facility’s nurse’s notes for Resident # 1. 43. A nurse’s note dated 02/04/05 at 5:00 p.m. documented that the resident exhibited labored respirations with chest congestion and that the resident was unable to cough up any mucous. 44. The nurse documented that the resident had an oxygen saturation level of 84%. 45. According to the nurse’s note, the resident’s nasal cannula was changed to an oxygen mask to aid in breathing and a breathing treatment was administered which raised the resident’s oxygen saturation level to 90%. 47. The Respondent facility failed to have any documentation in the resident’s records to indicate that the resident’s physician was notified of the resident’s breathing difficulties nor the need change the resident’s nasal cannula to an oxygen mask. 48. At 5:30 p.m. on 02/04/05, the resident's family was in attendance at the facility. According to the resident’s nurse’s notes, the resident kept removing the oxygen mask from his/her face and the resident’s family removed the oxygen mask and re-applied the nasal cannula. 49. Staff failed to determine the resident’s oxygen saturation level after the change and/or removal of the respiratory apparatus which was being used to supply oxygen to the resident. 50. In addition, the resident’s record still failed to indicate that the resident's physician was contacted regarding the resident’s condition. S1. On 02/05/05 at 12:00 a.m.. the resident’s nurse’s notes indicate that the resident continued to have labored respirations with chest congestion. 52. At that time, the resident’s oxygen saturation level was documented as 82% with the oxygen mask in place. 52. Again, the physician was not notified of the change in condition. 53. On 02/05/05 at 2:35 a.m., the resident was found unresponsive with an absence of vital signs. Cardio-pulmonary resuscitation was initiated and the paramedics were called, however, the paramedics were unsuccessful in resuscitating the resident. 54, Agency representatives conducted an interview with the resident's physician on 02/24/05 at 2:00 p.m. 55. The physician stated that he/she would have expected nursing staff on duty to notify him/her by phone that the resident’s oxygen saturation levels were 82% and 84%. However, the physician stated that he/she was not notified. 56. On 02/24/05, Agency representatives reviewed the facility’s policy and procedure manual which was dated July 1998. 57. The facility’s policy and procedure addressing respiratory care and pulse oximetry stated that oxygen saturation levels are to be monitored every two (2) hours and that the physician was to be notified immediately if results of testing are outside of expected ranges or as a patient's clinical condition indicates. 58. According to the resident's care plan, dated 01/28/05, for recurrence of respiratory problems, staff were required to assess the resident’s respiratory system and monitor the resident’s oxygen saturation levels. 59. A telephone interview was conducted on 02/24/05 with the Registered Nurse (“R.N.”) who was on duty during the 11:00 p.m. to 7:00 a.m. shift on 02/04/05 through 02/05/05. 60. According to the R.N., a Licensed Practical Nurse (“I.P.N.”) was assigned to care for Resident #1 during the shift and the L.P.N. told him/her that the resident's oxygen saturation level was 82%. 61. According to the R.N., she “offered assistance” to the L.P.N. and the L.P.N. stated that he/she would advise him/her if help was needed; however, the R.N. failed to personally assess the resident despite the residents low oxygen saturation levels and signs and symptoms of respiratory distress. 62. The R.N. stated that he/she never observed or assessed the resident until the resident was found unresponsive at 2:35 a.m. 63. A telephone interview was conducted on 02/25/05 with the L.P.N. on duty who was assigned to provide care to Resident # 1 during the 11:00 p.m. to 7:00 a.m. shift on 02/04/05 through 02/05/05. 64. According to the L.P.N., he/she had been told by the previous shift that the resident had been experiencing breathing difficulties on the 3:00 p.m. to 11:00 p.m. shift and needed to be watched closely. 65. According to the L.P.N., the resident was "OK" at the start of the shift, but by approximately 12:00 a.m., the resident's respirations were labored and the resident’s oxygen saturation level was at 82%. The L.P.N. stated that he/she took the resident’s vital signs and suctioned the resident, which, according to the L.P.N., brought the oxygen saturation level up to 92%. 66. According to the L.P.N., the L.P.N. observed the resident at 1-00 a.m. and the resident appeared to be sleeping. 67. The L.P.N. stated that he/she did not call the resident’s physician to notify the physician of the resident's low oxygen saturation levels and/or signs and symptoms of respiratory distress. 68. On 02/25/05, no further documentation was present at the facility which noted that the facility’s staff conducted any additional monitoring, observation, and/or assessment of the resident until 2:35 a.m. when the resident was found unresponsive. In addition, the staff members interviewed also failed to present any additional evidence that further monitoring, observation, and/or assessment of the resident was performed. 69. The Agency found no evidence of an assessment performed by the R.N. during the evening shift (11:00 p.m. to 7:00 a.m.), no evidence of an appropriate respiratory assessment being performed by any nursing staff member, no evidence of vital signs being monitored, no evidence of oxygen saturation levels being monitored every two (2) hours as required by the facility’s policy and procedure manual, and no evidence that the resident’s physician was contacted to report the resident’s signs and symptoms of respiratory distress and/or low oxygen saturation levels. 70. Resident # 4's diagnoses included congestive heart failure (“CHF”), coronary- obstructive pulmonary disease (“COPD”), coronary artery disease (“CAD”), and shortness of breath (“SOB”). 71. The resident’s current Physician Orders Shect, dated 02/05, was reviewed and included oxygen via nasal cannula (“N/C”) when needed for Dyspnea (shortness of breath) if oxygen staturation level is less than 90 % and oxygen saturation levels as needed (“PRN”). 72, Review of the resident's care plan, dated 01/20/05, indicated that oxygen saturation levels would be obtained every shift and maintained at greater thar. 92%. 73. On 02/24/05 at 5:30 p.m., the resident was observed in his/her room with a nasal cannula in place. 74, The resident stated that he/she needs oxygen at all times and has an oxygen tank attached to the wheelchair in the event that he/she leaves the room. 75. Further record review revealed that the resident’s oxygen saturation levels were not recorded on each shift. 76. During an interview on 02/24/04 with the Care Plan Coordinator (“CPC”), the CPC confirmed that the resident’s oxygen saturation levels were not being obtained on each shift and had no explanation as to why the resident’s care plan did not reflect the physician’s orders in regards to the ordered oxygen saturation levels. 77. The CPC further stated that the resident always receives contiruous oxygen. 78. At that point in the interview, the CPC revised the care plan to reflect the physician's orders. 79. After surveyor intervention, on 02/25/05, Resident # 4's medical record was reviewed again and there was a new clarification order regarding the resident's oxygen, 80. The new physician’s order stated, “O2 via nasal cannula continuous 2 L O; Sats (saturation level) shiftly + prn (as needed) maintain O2 Sats > 90%.” 81. The resident's care plan had been changed to reflect the new physician's order. 82. The aforementioned allegations reflect a failure of the facility to appropriately monitor, assess, and provide services for residents in need of oxygen to maintain appropriate and/or sufficient oxygenation levels. 12 83. The Agency determined that Respondent had not provided the necessary care and services and had compromised the residents’ ability to maintain or reach theiz 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 an isolated State Class II deficiency. The Agency is authorized to impose a fine in the amount of two thousand five hundred dollars ($2,500) for an isolated State Class II deficiency. 84. The Agency provided Respondent with a mandatory correction date for this deficient practice of 03/04/05. 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 85. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5), paragraphs seven (7) through thirty-one (31), and paragraphs thirty-three (33) through eighty-four (84) as if fully set forth herein. 86. Based upon Respondent’s two cited State Class II deficiencies, 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 Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7)(b). Fla. Stat. (2004), commencing 02/25/05 and ending 03/10/05. ime) fh Respectfully submitted this | Q day of May 2005. Humber irr — Imberly “Murtay aan Fla. Bar. No. 571628 Agency for Health Care Administration $25 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. CERTIFICATE OF SERVICE [ HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No: 7003 1010 0002 4667 1712 on May (Qh 2005 to: Eloise Abrahams, Administrator, Parks Healthcare and Rehabilitation Center, 9311 S. Orange Blossom Trail, Orlando, Florida 32837 and by U.S. Mail to: C.T. Corporation System, Registered Agent, Parks Healthcare and Rehabilitation Center, 1200 South Pine Island Road, Plantation, Florida 33324, Tonburly mM. Musrau mberly M. Murray, Esqtire Copies furnished to: Eloise Abrahams Administrator Parks Healthcare and Rehabilitation Center 9311 S. Orange Blossom Tr. Orlando, Florida 32837 (U.S. Certified Mail) C.T. Corporation System Registered Agent Parks Healthcare and Rehabilitation Center 1200 South Pine Island Rd. Plantation, Florida 33324 (U.S. Mail) Kimberly M. Murray Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 (Interoffice) 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. Parks Healthcare and Rehabilitation Center Facility Name 2005003038 2005002275 AHCA Case Nos.

Docket for Case No: 05-002185