- STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA Nos.: 2005005404 (CL) 2005005001 (FINE) vs. SA-CLEWISTON, LLC, d/b/a 0 a) /t i+ / GRACE HEALTHCARE OF CLEWISTON, Respondent. I ADMINISTRATIVE COMPLAINT \ COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (‘AHCA” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against SA- CLEWISTON, LLC, d/b/a GRACE HEALTHCARE OF CLEWISTON (“Respondent”), pursuant to Sections 120.569, and 120.57, Florida Statutes, and alleges: NATURE OF THE ACTION 1. This is an action to impose an administrative fine in the amount of TVO THOUSAND DOLLARS ($2,000.00) pursuant to Section 400.23(8), Florida Statutes (2004). 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7)(b), Florida Statutes (2004). Page 1 of 14 3. . The Respondent was cited for violations during a survey on or about May 17, 2005 through May 19, 2005; as a result of the follow- up, the Respondent was cited for one uncorrected Class III deficiency and assigned conditional licensure status. JURISDICTION AND VENUE 4. The Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004) and 28-106, Florida Administrative Code (2004). 5. AHCA, Agency for Health Care Administration, has jurisdiction over Respondent pursuant to Chapter 400, Part II, Florida Statutes (2004). 6. Venue shall be determined pursuant Section 120.57, Florida Statutes (2004), and to Rule 28-106.207, Florida Administrative Code (2004). PARTIES 7. AHCA is the regulatory agency responsible for licensure of nursing homes and enforcement of all applicable federal regulations, state statues and rules governing skilled nursing facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended); Chapter 400, Part Il, Florida Statutes; and Chapter 59A-4, Fla. Admin. Code, respectively. 8. Respondent is a 155-bed skilled nursing facility located at 301 South Gloria Street, Clewiston, Hendry County, Florida 33440. Page 2 of 14 Respondent is and was at all times material hereto, a licensed facility under Chapter 400, Part II, Florida Statutes (2004), and Chapter 59A-4, Florida Administrative Code (2004), having been issued license number 1092096. 9. Respondent was assigned by AHCA a conditional license status with an effective date of May 19, 2005, and certificate number 12602. {Exhibit A). COUNT I THE RESPONDENT FAILED TO ENSURE THAT RESIDENTS RECEIVE NURSING SERVICES AS ESTABLISHED BY THE PROFESSIONAL STANDARDS OF PRACTICE. THIS IS EVIDENCED BY THE FAILURE OF THE NURSING STAFF TO ADMINISTER MEDICATIONS OR SUPPLEMENTS AS ORDERED BY THE PHYSICIAN VIOLATING Section 464.003 (3)(a) and (b), Florida Statutes (2004) Section 42 CFR 483.20 (k)(3)(i), Resident Assessment UNCORRECTED CLASS III DEFICIENCY 10. The Agency re-alleges and incorporates paragraphs (1) through (8) as if fully set forth herein. 11. The regulatory provisions of the Florida Statutes that are pertinent to this alleged violation, reads as follows: Section 464.003 (3)(a) and (b) (3)(a) "Practice of professional nursing,” “means the performance of those acts requiring specialized knowledge, judgment, and nursing skill based upon applied principles of biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention and evaluation, health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. Page 3 of 14 - 2. The administration of medications and treatments as prescribed or authorized by a licensed practitioner authorized by the laws of this state to prescribe medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of above acts. (b) “Practice of practical nursing” “means 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, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist...” 12. The regulatory provisions of the Code of Federal Regulations that are pertinent to this alleged violation, reads as follows: Section 42 CFR 483.20 (k)(3)(i), Resident Assessment. (k) “Comprehensive care plans. (1) The facility must develop a comprehensive care plan for each resident that inchides measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment... (3) The services provided or arranged by the facility must— a) Meet professional standards of quality...” 13. AHCA surveyors conducted a survey on or about May 17, 2005 through May 19, 2005, of the Respondent’s facility. AHCA cited the Respondent for an uncorrected Class III violation. 14. Based on clinical record reviews and an interview with the facility's Director of Nursing (DON), the facility failed to ensure that 4 actively sampled residents (Residents #2, #3, #21, and #28) received nursing services as established by the professional standards of practice, which is evidenced by the failure of the nursing staff to administer Page 4 of 14 medications or supplements as ordered by the physician. The findings include: |. Resident #2 was readmitted to the facility on 9/3/04, with a diagnosis including, but not limited to, insulin dependent diabetes. The resident is also a dialysis patient. Review of the Medication Administration Record (MAR), revealed the resident receives insulin on a scheduled and sliding scale basis. a) Additional review of the Medication Administration Record (MAR) revealed that on 5/9/05, the resident's blood sugar was 259 at 6:00 a.m.. The resident received four units of insulin. According to the Physician orders the resident should have been given six units of insulin. b) Interview with the DON on 5/ 18/05, confirmed the above information. 2. Resident #3 was readmitted to the facility on 3/7/05, with multiple diagnoses of pneumonia and acute respiratory failure. Clinical record review revealed the resident had weight loss issues and is on Megace to increase appetite. a) Physician orders written on 5/3/05 stated, "If PO (oral intake) is less than 50% @ (at) meals provide 240cc house supplement 2.0 Resource and record %." The MAR had a hand written entry, which read, "if PO less than 50% @ meals, provide 240cc and record." The written orders did not include what the nurse should be giving to the resident. Indicators for dates 5/8/05 through 5/17/05, had various numbers ranging from 0 - 75. The numbers did not indicate if this was the amount of meal intake or the amount of the 240ce of unknown product. ‘ b) Interview on 5/18/05 with the DON confirmed there was no indication the resident has been receiving supplements as ordered. 3. Resident #21 is a diabetic and receiving insulin on a scheduled and sliding scale basis. Review of the MAR revealed: a) On 5/12/05 at 6:30 a.m., the resident's blood sugar was 327. The resident was administered four units of insulin. Physician orders stated that the resident should have been given six units of insulin. b) On 5/17/05 at 8:30 p.m., the resident's blood sugar was 400, and the resident received 10 units of insulin. Physician orders stated the resident should have been given eight units of insulin. 4. Resident #28 is diabetic and receiving insulin on a sliding scale basis. Review of the MAR revealed that on 5/17/05 at noon, the resident's blood sugar was 198. The Page 5 of 14 resident avas given two units of insulin. Physician orders did not include insulin coverage for blood sugars below 200. 15. The Respondent was provided a mandated correction date of June 19, 2005. 16. On or about April 7, 2005, AHCA conducted a survey at the Respondent’s facility. 17. Based on clinical record reviews, staff interviews and facility policy reviews, services provided to 6 randomly sampled residents (Residents #1, #2, #4, #17, #27, and #28) failed to meet professional standards as evidenced by administering discontinued medications, failure to complete daily monitoring of fluid intake for a resident on fluid restriction per physician orders, failure to complete a physician's order for a repeat urine culture and sensitivity, and failure to provide perineal and catheter care in accordance with standards of practice and facility policy. 1. Resident #1 was admitted to the facility on 7/24/04 with diagnoses including diabetes mellitus, hypertension, morbid obesity, elephantitis lower leg, hyperlipedemia, and depression. a) Physician orders included Zinc Sulfate 220 mg. capsule, one capsule daily; Heparin 5,000 wml, 1 ml subcutaneously (SQ) every 12 hours, rotate sites, and Acetaminophen 325 mg orally every 4 hours as needed for pain or temperature 4 doses, then call doctor, and Acetaminophen 650 mg suppository every 4 hours as needed for pain or temperature 4 doses, then call doctor. b) Further review of the physician orders indicated Zinc Sulfate was discontinued on 3/30/05. c) Review of the Medication Administration Record (MAR) for April 2005 indicated the resident received Zinc Sulfate 220 mg. on 4/1 through 4/4. Heparin 5,000 u/ml, 1 ml SQ is indicated on the MAR. There is no documentation of the site Page 6 of 14 rotation used for injection. Acetaminophen does not include parameters for use regarding temperature elevation. d) An interview and document review with the Unit Manager on 4/4/05, at approximately 11:10 a.m., verified Zinc Sulfate was discontinued on 3/30/05, there was no site rotation indicated on the MAR, and Acetaminophen did not include parameters for use with temperature. 2. Observations of perineal/catheter care for Resident #28 on 4/7/05, at approximately 10:15 a.m., revealed the resident was positioned on her back, and the perineal area was exposed. The Certified Nursing Assistant (CNA) used Prevail wipes with gloved hands to wipe the perineal area, The left hand, fingers pointed upward, was used to open the labia. The right hand pushed the wipe downward through the left hand to cleanse the area. Using the same hand placement, a Prevail wipe was used to cleanse the catheter starting at the end closest to the perineum and in the direction away from the body. This was repeated using the same wipe. a) The CNA raised the side rail with gloved hands. She repositioned the resident on the left side and cleansed the perineum and buttocks. A dry wash cloth was used to pat the area dry. The resident was retumed to her back, and the CNA used a dry wash cloth to pat the perineal area dry. b) An interview with the CNA following the observation revealed if the residents do not have periwash spray, the wipes are used. She indicated she had attended an in-service on 4/6/05 regarding pericare. c) An interview on 4/7/05, at approximately 11:05 a.m., with the Clinical Quality Manager and the Director of Nursing to review of the facility policy and procedure revealed soap and water is standard practice for catheter care. d) The in-service, dated 4/6/05, indicated the subject as "Peri Care-Catheter Care. The outline included the use of periwash. 3. Resident #2 has a diagnosis of, but not limited to chronic renal failure, heart failure epilepsy, and requires dialysis treatments three times a week for the renal failure. The physician's order for this resident restricts fluid intake to a total of 1500 cc per day. Observations on 04/04/05 at 12:15 p.m. and 04/05/05 at 11:30 a.m. showed that a 16 ounce styrofoam cup of water was placed at the resident's bedside both days. When interviewed on 04/05/05 at 11:30 a.m. about having water at the bedside, the resident stated, "They bring it but I don't drink it. I'm not supposed to have it, [J receive} dialysis.” a) Review of the resident's record shows documentation of fluid intake is absent on 04/02/05, 03/30/05, 03/28/05, and 03/06/05. Documentation of fluid intake on 03/04/05 shows an intake of 1680 cc of fluid, 04/01/05 a fluid intake of 2160 cc is recorded, 1680 cc fluid intake is documented on 04/03/05. Page 7 of 14 b) Review of the facility Clinical Standards of Care for residents receiving dialysis shows that "Resident's on fluid restriction will have fluid intake recorded.” 4, Observation of perineal/catheter care for Resident #27 on 4/7/05, at approximately 10:50 a.m., revealed the resident was positioned on her back, and the perineal area was exposed. The Certified Nursing Assistant (CNA) used Prevail wipes with gloved hands to wipe the perineal area. After the completion of perineal care the CNA used a Prevail Wipe to cleanse the Foley catheter. a) An interview with the Clinical Quality Manager and the Director of Nursing on 4/7/05, at approximately 11:05 a.m., for review of the facility policy and procedure, revealed soap and water is standard practice for catheter care. 5. Resident #4 had a urinalysis with culture and sensitivity completed 01/19/04, which was positive for E. Coli infection. The physician ordered Septra DS antibiotic treatment for 10 days and ordered a repeat culture and sensitivity to be done. The results of a repeat urine culture and sensitivity were not found in the clinical record. On 04/04/05, at 1:40 p.m., unit staff reviewed the Lab Book and clinical record. Evidence that the repeat urinalysis was completed could not be found. 6. Resident #17 has a physician's order for Tylenol 325 mg, two tablets every four hours, as needed, for pain or temperature. This Tylenol order does not include parameters for use regarding temperature elevation. 18. For this Class Ill deficiency, AHCA provided the Respondent a mandated correction date of May 7, 2005. 19, The Respondent was given written notification of the cited deficiency and the time frame for correction. 20. The above actions or inactions are uncorrected violations under Section 464.003(3)(a) and (b), Florida Statutes, which establishes 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, a licensed physician, a licensed osteopathic physician, Page 8 of 14 a licensed podiatric physician, or a licensed dentist.” and Section 42 CFR 483.20(k)(3)(1) which states that services provided or arranged by the facility must meet professional standards of quality. 21. Due to the nature of the violations, and its effects on the residents of the facility, the Agency for Health Care Administration seeks to impose a fine in the amount of TWO THOUSAND DOLLARS $2,000.00 for the uncorrected Class Ill citations under Sections 400.23(8) and 400.102, Florida Statutes. 22. Class Ill deficiencies are deficiencies that the Agency determines will result in no more than a minimal physical, mental or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental or psychosocial well being. A Class Ill deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency and $3,000 for a widespread deficiency. 23. Pursuant to Section 400.23(8)(c), Florida Statutes, the foregoing is a patterned Class III deficiency. 24. Pursuant to Section 400.23(7)(b), Florida Statutes (2004), the Agency is authorized to assign a conditional licensure status to the Respondent’s facility when at the time of the survey there exists a Class Ill deficiency not corrected within the time established by the Agency. The Respondent’s facility had failed to timely correct the Class III deficiency, which was present at the time of the survey. Page 9 of 14 WHEREFORE, AHCA request this Court to order the following relief: CLAIM FOR RELIEF 1. Make factual and legal findings in favor of AHCA on Count I. 2. Impose a fine of TWO THOUSAND DOLLARS ($2,000.00) for the violation cited in Count I against the Respondent under Sections 400.23(7)(b) and; 3. Uphold the assignment by the Agency of a conditional licensure status. 4. All other general and equitable relief allowed by law. DISPLAY OF LICENSE Pursuant to Section 400.23(7), Florida Statutes, GRACE HEALTHCARE OF CLEWISTON shall post the license in a prominent place that is in clear and unobstructed public view at or near the place where residents are being admitted to the facility. The Conditional License and its renewal are attached hereto as composite Exhibit “A”. NOTICE GRACE HEALTHCARE OF CLEWISTON is hereby 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: Agency Clerk, Agency for Health Care Page 10 of 14 Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, Florida, 32308, Telephone number: (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. 2 Sid Respectfully submitted on this “4 day of w ¥ 2005. x r _ FNM 37 Eric R. Brederneyer Assistant General Counsel Fla. Bar No.: 318442 Agency for Health Care Administration 2295 Victoria Avenue, Rm 346C Ft. Myers, Florida 33901-3884 Tel.: (239) 338-3203 Fax. (239) 338-2699 Page 11 of 14 . CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by postage paid U.S. Certified Mail return receipt (No. 7004 2510 0007 6070 8995) to: Traci Owens, Administrator, Grace Healthcare of Clewiston, 301 South Gloria Street, Clewiston, Florida 33440 and by U.S. Certified Mail return receipt (No. 7004 2510 007 6070 8988) to: Registered Agent, Kenneth A. Levine, Grace Healthcare of Clewiston, 101 N. Monroe Street, Suite 725, Tallahassee, Florida 32301 A on this 2) day of Su \y 2005. EesJGED Eric R. Bredemeyer, Esquire Page 12 of 14

Docket for Case No: 05-002889