STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case No. 2005003046 THE PLACE AT MAITLAND, INC., d/b/a PLACE AT MAITLAND (THE), Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency For Health Care Administration (hereinafter Agency), by and through the undersigned counsel, and files this Administrative Complaint against THE PLACE AT MAITLAND, INC., d/b/a PLACE AT MAITLAND (THE) (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2004), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $5,000.00 and a survey fee of $500.00 based upon one cited State Class II deficiency pursuant to §400.419(2)(b) Fla. Stat. (2004). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to $§ 20.42, 120.60 and 400.407, Fla. Stat. (2004). 2. Venue lies pursuant to Fla. Admin. Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable federal regulations, state statutes and rules governing assisted living facilities pursuant to the Chapter 400, Part ILI, Florida Statutes. and; Chapter 58A- 5 Fla. Admin. Code, respectively. 4. Respondent operates a | 16-bed assisted living facility located at 740 N. Wymore Road, Maitland, Florida 32751, and is licensed as an assisted living facility, license number 9415. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I! 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Pursuant to Florida law, all staff shall exercise their responsibilities, consistent with their qualifications, to observe residents, to document observations on the appropriate resident's record and to report the observations to the resident’s health care provider. Fla. Admin. Code R. §8A-5.019(2)(b) and §400.4255(1)(a), Fla. Stat. (2004). 8. That on February 16, 2005, the Agency conducted a complaint investigation of the Respondent facility. 9. That based upon the review of records and interview, the facility failed to ensure that one resident in a sample of four was observed after experiencing a fall, that the observations as they occurred were documented, and that the resident’s physician was not kept informed of observed changes and persistent complications in the resident’s condition. 10. That the Petitioner’s representative reviewed the clinical records of resident number one on February 16, 2005. 11. That the resident's progress notes reflected the following: That on January 12, 2005, an entry of 10:30 AM indicated that the resident had fallen in the bathroom, That the resident’s nurse practitioner Ordered an X-Ray of the resident’s foot and provided nitroglycerin, though not prescribed, for the resident’s chest pain; That on January 13, 2005, an entry of 9:45 AM by a nurse reflected that the resident’s right foot was swollen, hot to the touch, bruised and painful; That a late entry, written after January 14, 2005, indicated that at 8:15 AM on January 14, 2005, the resident’s foot was swollen, warm to the touch, and had bruising by the arch; That further late entries reflected that the nurse checked the resident two more times on January 14, 2005, noting that the resident’s foot remained swollen and warm to the touch; That on January 15, 2005, in an entry of 3:00 PM, a nurse memorialized that the resident was complaining of nausea, That on January 15, 2005, an entry of 5:05 PM noted that the resident had vomited, had no carotid pulse, and the resident’s body was cold to the touch. That the Resident’s death certificate listed the cause of death as complications of leg fracture and pulmonary thromboembolism. That the Petitioner’s representative interviewed the Respondent’s staff member who had found the resident on the bathroom floor on January 12, 2005. we 16. That the staff member indicated the following: a. That the resident was found on the bathroom floor laying on his back with the left leg pinned up beneath him; b. That staff pulled the resident’s leg from beneath the resident; c. That the resident requested Tylenol. That the staff member, along with another staff member of the facility, indicated that the resident was in his wheel chair the remainder of the day January 12, 2005. That the Petitioner’s representative interviewed the resident’s nurse practitioner several times during the survey and the nurse practitioner indicated the following: a. That she had visited the resident on January 12, 2005 while at the Respondent facility after the resident had experienced a fall; b. That nitroglycerin and patch was directed for the resident’s complaint of chest pain; c. That she had been notified on January 13, 2005, that the resident’s foot was swollen and bruised; d. That she had not been told that the resident’s leg had been bent in the fall and thus ordered only an X-ray of the resident’s foot; e. That the next contact from the Respondent staff was on January 14, 2005, indicating that the resident’s foot X-ray was negative; f. That she was not told that the x-ray results indicated ‘...very limited study — pt paralyzed, unable to get optimal positioning.” g. That had she known the resident’s leg had been pinned, an X-ray of the leg would have been ordered. 17. That Petitioner's representatives could not locate in the records any indicia that the following had occurred: a. That the resident’s request for or whether the resident received Tylenol or any pain medication was not annotated; b. That the continued observations of the resident’s swollen foot. including its bruising, heat to the touch, and complaints of pain were reported to the resident’s physician other than the initial report to the nurse practitioner on the morning of January 13, 2005; c. That the resident’s physician was contacted by facility staff when the resident complained of nausea on January 15, 2005; d. That regular monitoring and observation of the resident was conducted, documented, or reported to the resident’s physician. 18. That facility staff failed to exercise their responsibilities in monitoring resident number one after the resident suffered a fall. The records reflect no monitoring of the resident’s condition from 10:30 AM on January 12, 2005, until nearly twenty-four hours later on January 13, 2005 at 9:45 AM. Nearly another twenty-four hours passed before another documented monitoring of the resident occurred at 8:15 AM on January 14, 2005. 19. Where and when observation of and monitoring of the resident’s continuing condition of the resident’s foot and leg was conducted, noted observations were not reported to the resident’s physician as required by law. 20. That facility staff failed to exercise their responsibilities in failing to report to the resident’s physician upon the resident’s complaints of nausea after suffering a fall three days earlier for which no documented treatment was provided. ET ne eareee meee on en 21. That the Agency determined that this deficient practice was related to the personal care of the resident that directly threatened the health, safety, or security of the resident and cited Respondent for a State Class II deficiency. 22. The Agency provided Respondent with a mandatory correction date of February 17, 2005. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(2)(b), Fla. Stat. (2004). COUNT II 23. The Agency re-alleges and incorporates paragraphs (1) through (5) and (7) through (21) as if fully set forth herein. 24, That as a result of the Agency’s complaint investigation ending February 16, 2005. the Respondent was cited for one Class II deficiency which arose from the subject of the complaint. 25. That pursuant to Section 400.419(10), Florida Statutes (2004), AHCA is authorized to, in addition to any administrative fines, assess a survey fee equal to the lesser of one-half of the facility’s biennial license and bed fee, or $500, to cover the cost of conducting the initial complaint investigations that result in the finding of a violation that was the subject of the complaint, or for monitoring visits conducted under 400.428(3)(c), Florida Statutes (2004), to verify the correction of the violations. In this case, AHCA is authorized to request a survey fee in the amount of $500.00. WHEREFORE, the Agency intends to impose an additional survey fee of $500.00 against Respondent, an assisted living facility in the State of Florida, pursuant to § 400.419(10), Fla. Stat. Respectfull¥ submitted this % day of May, 2005. Thomas ke Fla. Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) 727.552.1440 (fax) Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Specific options for administrative action are set out in the attached Election of Rights (one page) and explained in the attached Explanation of Rights (one page). All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE T 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 0821 May Lho 2005 to Donna Holshouser Stinson, Esq., BROAD and CASSEL, 215 S. Monroe St. #400, Tallahassee, Florida 32301. shite iT 7 nior Attorney Copies furnished to: Donna Holshouser Stinson, Esq. Thomas J. Walsh, II BROAD and CASSEL Agency for Health Care Admin. | 215 S. Monroe St. #400 525 Mirror Lake Drive, 330G Tallahassee, FL 32301 St. Petersburg, Florida 33701 (U.S. Certified Mail) (Interoffice) “pl mp ton Boe PAYMENT FORM OS JUN28 PH 4: 18 ' Agency for Health Care Administration Finance & Accounting Post Office Box 13749 Tallahassee, Florida 32317-3749 Enclosed please find Check No. _in the amount of $ , which represents payment of the Administrative Fine imposed by AHCA. The Place at Maitland 2005003046 Facility Name AHCA No. STATE OF FLORIDA{PRIVATE } ov AGENCY FOR HEALTH CARE ADMINISTRATION Os i i Bp Nps "=F EXPLANATION OF RIGHTS UNDER SEC. 120.569, FLORIDA STATUTERS, (4 by 4 (To be used with Election of Rights for Administrative Complaint form attached) . In response to the allegations set forth in the Administrative Complaint issued by the Kaeneyer Health Care Administration (‘AHCA’ or “Agency”), Respondent must make one of the following elections within twenty-one (21) days from the date of receipt of the Administrative Complaint and your Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date you receive the Administrative Complaint. Please make your election on the attached Election of Rights form and return it fully executed to the address listed on the form. OPTION 1. If Respondent does not dispute the allegations in the Administrative Complaint and Respondent elects to waive the right to be heard, Respondent should select OPTION 1 on the election of rights form. A final order will be entered setting forth the allegations as being deemed admitted and imposing the penalty sought in the Administrative Complaint. You will be provided a copy of the final order. OPTION 2. ‘If Respondent does not dispute any material fact alleged in the Administrative Complaint (Respondent admits all the material facts alleged in the Administrative Complaint.), Respondent may request an informal hearing pursuant to Section 120.57(2), Florida Statutes before the Agency. At the informal hearing, Respondent will be given an opportunity to present both written and oral evidence to reduce the penalty being imposed for the violations set out in the Complaint. For an informal hearing, Respondent should select OPTION 2 on the Election of Rights form. OPTION 3. _ If the Respondent disputes the allegations set forth in the Administrative Complaint (you do not admit them) you may request a formal hearing pursuant to Section 120.57(1), Florida Statutes. To obtain a formal hearing, Respondent should select OPTION 3 on the Election of Rights form. In order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), F.S., Respondent’s request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts disputed. If you select Option 3, mediation may be available in this case pursuant to Section 120.573, Florida Statutes, if all parties agree to it. IF YOU SELECT OPTION 3, PLEASE CAREFULLY READ THE FOLLOWING PARAGRAPH: In order to preserve the right to a hearing, Respondent's original Election of Rights in this matter must be RECEIVED by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent's selected option is not received by AHCA within twenty-one (21) days from the date of Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. é STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Sy 2 (4 RE: THE PLACE AT MAITLAND, INC. CASE NO: 2005003046 /¥# bs d/b/a PLACE AT MAITLAND (THE) Ap eee '8 ELECTION OF RIGHTS FOR ADMINISTRATIVE COMPLAINT PLEASE SELECT ONLY 1 OF THE 3 OPTIONS An Explanation of Rights is attached. OPTION ONE (1) _ Respondent does not dispute the allegations of fact contained in the Administrative Complaint and waives Respondent’s right to object or to be heard. Respondent understands that by waiving Respondent's rights, a final order will be issued that adopts the Administrative Complaint and imposes the sanctions sought. OPTION TWO (2) _ Respondent does not dispute and Respondent admits the allegations of fact in the Administrative Complaint, but Respondent does wish to be afforded an informal proceeding, pursuant to Section 120.57(2), Florida Statutes, at which time Respondent will be permitted to submit oral and/or written evidence to the Agency in mitigation of the penalty imposed. OPTION THREE (3)___—- Respondent does dispute the allegations of fact contained in the Administrative Complaint and Respondent requests a formal hearing, pursuant to Section 120.571), Florida Statutes, before an Administrative Law Judge appointed by the Division of Administrative Hearings. If Respondent chooses OPTION THREE (3), in order to obtain a formal proceeding before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. Respondent’s request for an administrative hearing must conform to the requirements in Section 28-106.201, Florida Administrative Code (F.A.C), and must state the material facts you dispute. In order to preserve Respondent’s right to a hearing, Respondent’s original Election of Rights in this matter must be received by AHCA within twenty-one (21) days from the date Respondent receives the Administrative Complaint. If the election of rights form with Respondent’s selected option is not received by AHCA within twenty-one (21) days from the date of the Respondent’s receipt of the Administrative Complaint, a final order will be issued finding the deficiencies and/or violations charged and imposing the penalty sought in the Complaint. If Respondent has elected either OPTION TWO (2) or THREE (3) above and if Respondent is interested in discussing a settlement of this matter with the Agency, please also mark and check this block. { ). SEND NO PAYMENT NOW -- REGARDLESS OF THE OPTION SELECTED, PLEASE WAIT UNTIL RESPONDENT RECEIVES A COPY OF A FINAL ORDER FOR INSTRUCTIONS ON PAYMENT OF ANY FINES. (Please sign and fill in your current address.) Respondent (Licensee) Address: _ _. . a License. No. and facility type:_ Phone No. PLEASE RETURN YOUR COMPLETED FORM TO: Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS3#3, Tallahassee, FL 32308 Telephone Number: (850) 922-5873; FAX (850) 921-0158.

Docket for Case No: 05-002328

Orders for Case No: 05-002328