STATE OF FLORIDA EE py AGENCY FOR HEALTH CARE ADMINISTRATION 05 gp STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case Nos. 2005005464 2005005461 GINGER DRIVE HEALTH CARE ASSOCIATES, LLC, d/b/a HERITAGE HEALTHCARE CENTER, — 2 Respondent. OD | 5 / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against Ginger Drive Health Care Associates, LLC, d/b/a Heritage Healthcare 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 April 22, 2005, and to impose an administrative fine in the amount of $2,500.00, based upon the Respondent being cited for one State Class II deficiency for compromising its 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. 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 I'V, Subtitle C (as amended); Chapter 400, Part II, Florida Statutes, and; Fla. Admin. Code R. 59A-4, respectively. 4. Respondent operates a 180-bed nursing home located at 3101 Ginger Drive, Tallahassee, Florida 32308, and is licensed as a skilled nursing facility under license number SNF12210961. 5. At all times material hereto, Respondent was 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 by reference paragraphs one (1) through five (5) as if fully set forth herein. 7. Pursuant to 42 CFR § 483.25 and Fla. Admin. Code R. 59A-4.1288, each resident must receive and Respondent must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. 8. On or about April 18, 2005 through April 22, 2005, Agency representatives conducted an annual survey at the Respondent nursing facility (hereinafter the “facility”). 9. Based upon observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, “mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for two (2) of thirty-three (33) sampled residents. 10. Resident number twenty was admitted to the facility on January 17, 2005 with diagnoses that included status-post suprapubic catheterization, benign prostate hypertrophy and cerebrovascular accident. 11. According to a consultation report contained within resident number twenty’s records, the resident’s suprapubic catheter was changed without incident on April 15, 2005. 12. According to resident number twenty’s records, the resident had a history of urinary tract infections. 13. Physician progress notes, dated March 8, 2005 and March 25, 2005, documented that the resident had recurrent urinary tract infections. 14. A laboratory report for resident number twenty, dated March 17, 2005, indicated that the resident’s urine white count was “too numerous to count” (normal 0-3) and a urine culture and sensitivity indicated that the resident’s urine was positive for staphylococcus species. 15. Anadditional laboratory report, dated March 23, 2005, indicated that the urine white count was “too numerous to count” and a urine culture and sensitivity indicated that the resident’s urine was positive for staphylococcus species and isolated yeast. 16. On two separate occasions, Agency representatives observed resident number twenty sitting in a wheelchair with the catheter tubing from the resident’s suprapubic catheter dragging on the floor. 17. On April 19, 2005, at approximately 12:50 p.m., resident number twenty was observed during lunch seated in a wheelchair in the day room on Unit 3. 18. The tubing from the resident’s suprapubic catheter was observed dragging on the floor. 19. On April 21, 2005, at about 9:10 a.m. until 9:25 a.m., resident number twenty was observed seated in a wheelchair on Unit 3 in the day room eating break fast. 20. The tubing from the resident’s suprapubic catheter was observed draped and dragging on the floor under the resident’s wheelchair. The catheter tubing was attached to a drainage bag that was connected to the wheelchair. A blue cloth bag was covering the drainage bag. 21. From about 9:25 a.m. until 9:35 a.m., the resident was observed self-propelling himself in the day room toward his room with the catheter tubing dragging across the floor. 22. The Agency representatives then observed a housekeeping staff member push the resident into the resident’s room while allowing the catheter to continue to drag across the floor. 23. At about 9:40 a.m., Agency representatives observed a certified nursing assistant (“CNA”) place the tubing from the resident’s suprapubic catheter into the blue cloth bag that contained the drainage bag. 24. On April 21, 2005, Agency representatives observed the resident’s suprapubic catheter insertion site with a facility staff nurse. The resident was wearing a pair of briefs which the staff nurse pulled down to expose the resident’s lower abdomen and the suprapubic catheter insertion site. 25. The briefs were noted to have purulent brown moist drainage on them approximately the size of a fifty-cent piece located approximate to the catheter insertion site. 26. Interview was conducted with the staff nurse concerning the care of the suprapubic catheter site. The staff nurse indicated that he was responsible for cleaning around the insertion site. He stated that he cleans the insertion site with normal saline and gauze and leaves it open to air. 27. The staff nurse indicated that an order was not needed to cleanse the catheter site. 28. The staff nurse revealed that the suprapubic catheter site had not been cleansed on April 21, 2005. 29. The staff nurse indicated the he last cleansed the insertion site on April 20, 2005. However, the staff nurse indicated that he did not document that he had performed the care on the Medication Administration Record (“MAR”) or on the Treatment Administration Record (“TAR”). 30. Interview was conducted with the facility unit manager who is also a direct care staff nurse. 31. According to the unit manager/staff nurse, the suprapubic catheter insertion site should be cleansed with normal saline or “wound cleaner”. 32. The unit manager/staff nurse indicated that she was not aware if catheter site care was being performed. 33. In addition, the unit manager/staff nurse also indicated that she was not aware that resident number twenty had a urinary infection. 34. According to the unit manager/staff nurse, suprapubic catheter insertion site care should be documented on the TAR and should be initialed by staff to indicate when the procedure has been completed. 35. The unit manager/staff nurse indicated that she was on duty on April 18, 2005 and April 19, 2005 during the 7:00 a.m. to 3:00 p.m. shifts and was responsible for providing care to resident number twenty. 36. The unit manager/staff nurse indicated that on the two aforementioned days, she observed the urine in the resident’s catheter tubing and receptacle bag; however, she did not perform suprapubic catheter insertion site care for the resident nor did she assign anyone else to undertake this duty. 37. Interview was conducted with the director of nursing (“DON”). 38. According to the DON, the facility should have a physician’s order to perform the resident’s suprapubic catheter insertion site care. 39. The DON indicated that the physician’s order and staff documentation that the order has been carried out and/or completed should be the documented on a TAR. 40. Agency representatives reviewed resident number twenty’s records. 41. A care plan for the resident for risk of infection related to the suprapubic catheter was observed. 42. According to the care plan, facility staff were required to, inter alia, “Monitor [the resident’ s] urine for signs and symptoms of infection, as evidenced by (“AEB”) ... foul odor, burning pain, decreased urinary output, increased temperature, fatigue and report any abnormality(s) to [the] physician immediately.” (emphasis added). 43. The care plan required staff to perform “. . . [catheter] care every shift and as needed.” 44. The care plan also required staff to monitor urine output every shift. 45. Agency representatives reviewed the facility's policies and procedures. A nursing policy and procedure for suprapubic catheter care was observed. According to this facility policy and procedure, nursing staff are required to, inter alia: (a) verify the physician’s order for catheter care and maintenance; (b) (c) (d) (e) (f) (g) (h) (i) G) (k) 46. inspect the skin and catheter site for signs and symptoms of infection ([e.g.]. redness, drainage.); gently cleanse area and approximately three inches of the catheter with soap and warm water .. . start at stoma and work outward . . . hold and support catheter to avoid tension or unnecessary movement . . . gently rinse the area, making sure all soap is removed . . . pat the area dry; replace split-gauze dressing as applicable; secure the catheter to the abdomen with tape or Velcro multipurpose tube holder to reduce tension on insertion site; coil excess tubing on bed verifying there are no obstructions or kinks in tubing; document the following: (1) date and time; (2) condition of skin around suprapubic catheter; (3) condition of catheter; (4) changes in urine color; (5) complaints of pain or discomfort; and (6) resident/patient response to procedure. observe resident/patient for complaints or changes in condition; inspect site at least every shift; notify the physician of any changes or concerns in skin condition or urine output; and review and revise treatment plan, as indicated and per physician order. According to the suprapubic catheter care nursing policy and procedure, the purpose of the policy is to provide safe and proper care of a resident/patient with a suprapubic catheter by evaluating elimination status, minimizing risk of bladder infection, and maintaining skin integrity. 47. Another facility policy and procedure entitled “Indwelling Catheters” was observed. This policy and procedure states, inter alia, “Orders that accompany indwelling catheter .. . Catheter care (with soap and water) every shift (place on TAR)”. 48. The resident’s records were void of any physician’s orders that provided treatment orders for the care of the resident’s suprapubic catheter insertion site. 49. The resident’s records were void of any TARs demonstrating that care was being provided for resident number twenty’s suprapubic catheter insertion site. 50. The resident’s records were void of any Intake and Output (“I & O”) documentation to monitor the resident’s urinary output. 51. Interview with staff confirmed that the resident did not have a TAR that addressed the cleansing and care of the suprapubic catheter insertion site. 52. Staff also confirmed that the resident’s urinary output was not being documented. 53. Upon request by Agency representatives for resident number twenty’s TARs, a blank TAR was printed out for the resident. 54. Agency representatives attempted to contact by telephone the facility staff members who had been scheduled to provide care for the resident from April 16, 2005 through April 20, 2005. 55. Of the five staff members contacted, only one staff member placed a return call to the facility in response to messages left by the Agency representatives. A conference call was held with this staff member and the administrator, the DON, and two Agency representatives. 56. The staff nurse indicated that she was not sure if she remembered resident number twenty. However, when questioned about the care of the resident’s catheter insertion site, she indicated that she washed the site with soap and water. 57. The staff nurse further indicated that a physician’s order was required for the care of the insertion site. She also indicated that the care was not documented on a TAR; however, according to the staff nurse, it should have been documented on a TAR. 58. An interview was conducted with another staff nurse concerning the care of resident number two’s suprapubic catheter. 59. This staff nurse was on duty on April 17, 2005 and April 18, 2005 during the 3:00 p.m. to 11:00 p.m. shift and was responsible for providing care to resident number twenty. 60. The staff nurse indicated that she had cleansed the catheter site on the two aforementioned days with “wound cleaner”. She further indicated that she had been employed by the facility for 2 to 3 weeks and had been instructed to use “wound cleaner”. 61. Aninterview was conducted with resident number twenty. The resident was alert to person, place, and time (date) at the time of the interview. The resident indicated that he had a history of urinary tract infections. 62. During the interview, the resident indicated that facility staff had not performed any care to his suprapubic catheter insertion site. 63. After Agency representative intervention on April 21, 2005, nursing staff contacted the resident’s physician to report the purulent drainage that was noted on the resident’s suprapubic catheter site. 64. The resident’s physician ordered a culture (C&S) of the drainage from the site, cleansing of the site with normal saline followed by the application of Bactroban ointment twice a day (“BID”), and Keflex 500 mg. (an antibiotic) four times a day (“QID”) until the culture results were available. 65. Staff then initiated a TAR for the resident to address the cleansing orders for the suprapubic catheter site. 66. Resident number twenty-one was admitted to the facility on January 17, 2004 with diagnoses that included hyperlipidemia, hypertension, cerebrovascular accident, left hemiplegia, and aphasia. The resident has a gastrostomy tube (“G-tube”) for tube feedings. 67. Review of resident number twenty-one’s records revealed a laboratory report for a wound culture, dated April 5, 2005, which identified that the resident had a Staphylococcus aureus infection in his G-tube site. 68. Resident number twenty-one had physician’s orders, dated March 1, 2005 and April 1, 2005, which required staff to “cleanse G-tube site with normal saline or wound cleaner, [and] apply drainage dressing every shift and as needed." 69. __ A facility policy and procedure for G-tube site care was observed. The policy and procedure required staff to, inter alia, "review any special approaches to take when providing G-tube care, cleanse around the tube with normal saline unless otherwise ordered, rinse area well and gently dry, document time and date of treatment and site care completion, complete site care at least once per day, and review and revise treatment plan as indicated or ordered by the physician.” 70. Acare plan for the resident’s G-tube was observed; however, the care plan did not address any care that was to be provided to the G-tube insertion site or the tubing. 71. The facility did not have a care plan for resident number twenty-one addressing the resident’s risk for developing infections. 72. A TAR was observed for resident number twenty-one, dated March 1, 2005 through March 21, 2005, which stated, "cleanse G-tube site with normal saline or wound cleanser, apply drainage dressing every shift and as needed.” 73. The March 2005 TAR did not contain documentation that the G-tube site care was performed on the following 23 shifts: 03/01/05: 03/02/05 03/03/05 03/11/05 03/15/05 03/16/05 03/17/05 03/18/05 03/19/05 03/20/05 03/22/05 03/23/05 03/25/05 03/29/05 03/30/05 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts; 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts; 3:00 p.m. to 11:00 p.m. shift; 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. shift; 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. shift; 11:00 p.m. to 7:00 a.m. shift; 11:00 p.m. to 7:00 a.m. shift; and 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts. 74. A TAR was observed for resident number twenty-one for the month of April 2005 which stated, "cleanse G-tube site with normal saline or wound cleanser, apply drainage dressing every shift and as needed." 75. The TAR did not contain documentation that the G-tube site care was performed on the following 15 shifts during the period of April 1, 2005 through April 19, 2005: 04/01/05 04/02/05 04/04/05 04/09/05 04/10/05 04/13/05 04/14/05 04/16/05 04/17/05 04/18/05 04/19/05 3:00 p.m. to 11:00 p.m. shift; 11:00 p.m. to 7:00 a.m. shift; 7:00 a.m. to 3:00 p.m. shift; 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts; 11:00 p.m. to 7:00 a.m. shift; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. shift; 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts; 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. shifts; 3:00 p.m. to 11:00 p.m. shift; and 3:00 p.m. to 11:00 p.m. shift. 11 76. According to the TAR, during the period of April 5, 2005, which is the date the resident’s G-tube site infection was identified, through April 19, 2005, G-tube site care was not performed for the resident on 12 of 42 shifts. 77. Aninterview was conducted with the facility’s DON. The DON was familiar with resident number twenty-one and reported that the resident was a good historian. 78. Agency representative conducted an interview with resident number twenty-one. 79. The resident accurately reported that he receives 6 bolus tube feedings per day through his G-tube. The resident indicated the he sometimes administers the tube feedings himself, which was supported by the resident’s nursing and social services notes. 80. The resident indicated that facility staff fail to clean his G-tube site and/or change his G-tube site dressing on every shift and on some days the care is not performed at all. 81. Agency representatives interviewed a Licensed Practical Nurse (“L.P.N.”) who, according to the nursing assignment book, was responsible for providing care to resident number twenty-one on April 2, 2005 on the 11:00 p.m. to 7:00 a.m. shift. 82. The L-P.N. reported knowing the resident well as she had worked with the resident on all three shifts on multiple occasions. She also reported that she was aware that the resident receives two bolus feedings per shift. 83. According to the TAR, resident number twenty-one’s G-tube site care was not performed on April 2, 2005 on the 11:00 p.m. to 7:00 a.m. shift. 84. The L.P.N. confirmed that she had not performed the ordered G-tube care for resident number twenty-one on April 2, 2005 on the 11:00 p.m. to 7:00 a.m. shift. 85. According to the L.P.N., she was unaware of how often resident number twenty- one was required to receive G-tube insertion site care. She reported that she provided G-tube care for the resident when “the dressing is dirty”. 86. 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 IT deficiency. 87. The Agency provided Respondent with a mandatory correction date of May 22, 2005 for this deficient practice. 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 II 88. The Agency re-alleges and incorporates by reference paragraphs one (1) through five (5) and seven (7) through eighty-seven (87) as if fully set forth herein. 89. 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 Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7)(b), Fla. Stat. (2004), commencing April 22, 2005. 13 Respectfully submitted this _J GH day of August 2005. ™. Lr Kimberly M. Murray, Esquire 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No: 7004 2890 0004 7600 5398 on August L_, 2005 to: Elizabeth R. McGinley, Administrator, Heritage Healthcare Center, 3101 Ginger Drive, Tallahassee, Florida 32308, and by U.S. Mail to: Corporation Service Company, Registered Agent, Heritage Healthcare Center, 1201 Hays Street, Tallahassee, Florida 32301-2525 Kenburly MWh Kimberly M. Murray, Esquir Copies furnished to: Elizabeth R. McGinley Administrator Heritage Healthcare Center 3101 Ginger Drive Tallahassee, Florida 32308 (US. Certified Mail) Corporation Service Company Registered Agent Heritage Healthcare Center 1201 Hays Street Tallahassee, Florida 32301 (U.S. Mail) Kimberly M. Murray Senior Attorney Agency for Health Care Administration 525 Mirror Lake Drive, 330D St. Petersburg, Florida 33701 (Interoffice)

Docket for Case No: 05-003213