STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION Dn A heli Ue Abi tS Ce AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2005006183 AHCA No.: 2005006182 : v. Return Receipt Requested: 7002 2410 0001 4234 5605 WEST PALM BEACH HEALTH CARE 7002 2410 0001 4234 5612 ASSOCIATES, LLC, d/b/a AZALEA CouRT, 7002 2410 0001 4234 5629 (OS: 38712 ADMINISTRATIVE COMPLAINT Respondent. COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against West Pal Beach Health Care Associates, LLC, d/b/a Azalea Court (hereinafter “Azalea Court”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2004), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $5,000.00 pursuant to Section 400.23(8), Florida Statutes (2004), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Azalea Court, pursuant to Section 400.23(7) (b) Florida Statutes (2004). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2004), and Chapter 28- 106, Florida Administrative Code. 4. Venue lies in Palm Beach County, pursuant to Section 400.121(1) (e), Florida Statutes (2004), and Rule 28- 106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Florida Statutes, (2004), and Chapter 59A-4 Florida Administrative Code. 6. Azalea Court is a 120-bed skilled nursing facility located at 5065 Wallis Road, West Palm Beach, Florida 33415. Azalea Court is licensed as a skilled nursing facility; license number SNF1198096; certificate number 12653, effective 06/07/2005, through 11/30/2005. Azalea Court was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. 7. Because Azalea Court participates in Title XVIIT or XIX, it must follow the certification rules and regulations found in Title 42 C.F.R. 483, as incorporated by Rule 59A-4.1288, Florida Administrative Code. 2 COUNT I AZALEA COURT FAILED TO ENSURE NECESSARY CARE AND SERVICES TO ATTAIN OR MAINTAIN THE HIGHEST PHYSICAL WELL-BEING FOR ONE OF FIVE RESIDENTS TITLE 42, SECTION 483.13(c) (1) (i), Code of Federal Regulations, as incorporated by Rule 59A-4.1288, Florida Administrative Code. (STAFF TREATMENT OF RESIDENTS) CLASS II DEFICIENCY 8. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 9. During an abbreviated survey conducted on 6/07/05 and based on record review and interviews, it was determined the facility did not ensure that the necessary care and services to attain or maintain the highest physical well- being is provided for 1 of 5 (Resident #5). The resident did not receive hemodialysis treatments 3 times per week as ordered on 5/16/05. The resident expired on 05/23/05. 10. Review of the resident's (Resident #5) medical record on 06/07/05 revealed the resident was admitted to the facility from a local hospital on May 16, 2005. The resident's admitting diagnoses and past medical history includes Chronic Renal Failure for 10 years, Hemodialysis 3 times weekly, Diabetes Mellitus, Hypertension, Coronary Artery Bypass Graft and Cardiopulmonary Arrest. 11. The admitting nursing progress note dated 5/16/05 documents the resident is alert, non-verbal, and responds to tactile stimuli only. The resident was receiving Tube feed Renal Resource 40’ cc/hour via IV pump continuously with a daily fluid intake of 1200 ec. 12. The resident's vital signs on admission were blood pressure 140/90, pulse 94, respirations 20 and temperature 96.8 degrees Fahrenheit. 13. On 5/16/05 the physician ordered hemodialysis treatment three times per week on Monday/Wednesday/Friday. 14. A care plan dated 5/17/05 documents the resident is at risk for complications related to hemodialysis secondary to renal failure. Complications of chronic renal failure include fluid overload, shortness of breath, respiratory distress and chemical imbalance due to high levels of toxins in the blood. The planned approaches included prepare resident for hemodialysis and coordinate resident's care with dialysis center. 15. Another care plan dated 5/17/05 documents the resident is at risk for respiratory distress due to a history of cardiac arrest with diagnosis of congestive heart failure. The care plan goals and approached includes, "Resident will be free from signs of respiratory distress daily till next review date 8/18/05; the resident would be observed for signs of respiratory distress and report to physician." 16. A nursing progress note date 5/22/05 3:45 PM documents, "tube feeding discontinued, chest congested noted, call DR., waiting for the call back from Doctor, incoming nurse notified, will continue monitor and follow plan of care." 17. According to the nursing progress note the tube feeding was discontinued on 5/22/05 when the resident was observed to have lung congestion. 18. The nursing progress note subsequent to the 5/22/05 3:45 PM did not address the follow up plan of care for the resident's lung congestion and there is no documentation to indicate the physician was notified the resident had a change in condition on 5/22/05 at 3:45 and the tube feeding was discontinued. 19. On 5/23/05 at 6:00AM, the nurse documents "Resident's roommate states resident was "shaking" white frothing liquid secretion noted on mouth." 20. On 5/23/05 at 10:28 AM, the resident was found unresponsive in respiratory distress and had no. pulse. Cardiopulmonary resuscitation was initiated, the resident was pronounced dead at a local hospital on 5/23/05 at 10:52AM. 2i. Further review of the resident's medical record revealed the medical record did not contain documentation to substantiate the resident had received hemodialysis treatment for the period of 5/16/05 through 5/23/05. The resident's medical record did not contain documentation to indicate the care plan was implemented and hemodialysis treatment was coordinated with a dialysis facility. 22. Interview with the Director of Nursing (DON) and Staff Development Coordinator, a Licensed Practical Nurse on 6/7/05 at 11:30AM and 2:30PM revealed on 5/16/05 a case manager at a local hospital called the facility and informed the admission coordinator the resident would be discharged to the facility that day and dialysis treatment was arranged with a local Dialysis facility. The Director of Nursing stated, the charge nurse called the Dialysis facility on’ 5/17/05 to obtain a dialysis schedule and was told they would not accept the resident. 23. The DON and staff development coordinator stated that the resident did not have an advanced directive in the medical record so the resident's family was contacted regarding hospice care. The surveyor asked if the physician had recommended hospice care. The DON replied, "No." 24. The DON informed the surveyor she/he has reviewed the resident's (#5) medical record and there is no documentation to indicate the physician was notified that the resident had not received the prescribed hemodialysis treatment. 25. The staff development coordinator stated, it is common facility practice for the desk nurse/charge nurse to notify the doctor of changes, so she assumed the physician was notified. 26. Interview conducted on 6/7/05 at 3:05PM with Licensed Practical Nurse and charge nurse of 5/17/05, revealed the local Dialysis facility was contacted on 5/17/05 to obtain the resident's hemodialysis schedule. A nurse at the Dialysis facility informed him/her the dialysis facility did not have any record of the patient and would not accept a resident who is unresponsive. The nurse stated, later that day (5/17/05) he/she called the resident's family and other dialysis facilities to arrange dialysis treatment for the resident, but they would not accept the resident because the resident's was unresponsive and needed a stretcher during dialysis. 27. The Licensed Practical nurse stated, he/she did not inform the physician that the resident did not received hemodialysis treatment. 28. The Licensed Practical Nurse stated: he/she did not take any further action to ensure the resident received hemodialysis treatment. 29. Interview conducted with the social worker on 6/7/05 in the afternoon revealed on 5/19/05 she/he was informed by a nurse to contact the resident's family to obtain consent for hospice care because the resident had not received dialysis treatments since admission on 5/16/05. The social worker stated, she called the resident's wife and left a message, but the family did not contact the facility. The social worker stated she documented this information in the medical record on 5/20/05. 30. Interview conducted with the Administrator and Administrative Assistant at the Dialysis on 6/8/05 at 1:20PM revealed, the facility has no transfer record for this resident. 31. The Administrative Assistant is responsible for new patient medical records, he/she stated about two weeks ago a case manager at a local hospital facility to inquire if they would accept a patient who is unresponsive and needs to be dialyzed on a stretcher. The case Manager was informed; the facility could not accommodate the patient and recommended the case manager find a nursing home with in- house dialysis services. The administrative assistant stated, there was no other communication with a case manager or other staff from the local hospital. 32. Interview conducted with a case manager at the local hospital on 6/8/05 in the afternoon revealed on 5/13/05 the Dialysis facility was contacted to arrange dialysis for resident #5. The case Manager who made the dialysis arrangement was not available for interview. The case manager stated, the documentation in the hospital computer did not indicate the medical record was sent to the dialysis facility and the transfer arrangement was confirmed prior ,to the patient's discharge. 33. The resident's medical record at the Skilled Nursing Facility contains no documentation to substantiate the physician was notified that hemodialysis treatments were not administered to resident #5 for seven (7) days May 16- 23, 2005, as ordered. The facility did not obtain an order to send the resident to the hospital for evaluation and follow-up care when the dialysis treatment was not available at a dialysis facility. The facility did not ensure the physician was aware the resident had a change in condition and that the tube feeding was discontinued by the nursing staff. 34. Based on the foregoing, Azalea Court violated Title 42, Section 483.13 (c) (1) (i), Code | of Federal Regulations as incorporated by Rule 59A-4.1288, Florida Administrative Code, herein classified as a Class II deficiency pursuant to Section 400.23(8) (b), Florida Statutes, which carries, in this case, an assessed fine of $2,500.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). “COUNT II AZALEA COURT FAILED TO ENSURE THAT A NEWLY ADMITTED RESIDENT HAD PHYSICIAN ORDERS TO MEET THE IMMEDIATE CARE AND SERVICES NEEDED FOR ONE RESIDENT Section 483.20(a), Code of federal Regulations as incorporated by Rules 59A-4.1288 and 59A-4.109(1), Florida Administrative Code (RESIDENT ASSESSMENT) CLASS II DEFICIENCY 35. AHCA re-alleges and incorporates Paragraph (1) through (7) as if set forth herein. 36. During the abbreviated survey conducted on 6/07/05 and based on record review and interviews, it was determined that the facility did not ensure a newly admitted resident had physician orders to meet the immediate care and services needed for 1 of 5 sampled residents (Resident #5). The resident did not receive hemodialysis treatments 3 times per week as ordered on 5/16/05. The resident's physician was not notified that the resident was not receiving hemodialysis treatments for the period of 05/16/05 to 05/23/05. The resident expired on 5/23/05. 37. Review of the resident's (Resident #5) medical record on 06/07/05 revealed the resident was admitted to the facility from a local hospital on May 16, 2005. The resident's admitting diagnoses and past medical history includes Chronic Renal Failure for 10 years, Hemodialysis 3 times weekly, Diabetes Mellitus, Hypertension, Coronary Artery Bypass Graft and Cardiopulmonary Arrest. 38. The admitting nursing progress note dated 5/16/05 documents the resident is alert, non-verbal, and responds to tactile stimuli only. The resident was receiving Tube feed 10 Renal Resource 40 cc/hour via IV pump continuously with a daily fluid intake of 1200 ec. 38. The resident's vital signs on admission were blood pressure 140/90, pulse 94, respirations 20 and temperature 96.8 degrees Fahrenheit. 40. On 5/16/05 the physician ordered hemodialysis treatment three times per week on Monday/Wednesday/Friday. 41. A care plan dated 5/17/05 documents the resident is at risk for complications related to hemodialysis secondary to renal failure. Complications of chronic renal failure include fluid overload, shortness of breath, respiratory distress and chemical imbalance due to high levels of toxins in the blood. The planned approaches included prepare resident for hemodialysis and coordinate vesident's care with dialysis center. 42. Another care plan dated 5/17/05 documents the resident is at risk for respiratory distress due to ‘a history of cardiac arrest with diagnosis of congestive heart failure. The care plan goals and approached includes, "Resident will be free from signs of respiratory distress daily till next review date 8/18/05; the resident would be observed for signs of respiratory distress and report to physician." 43. A nursing progress note date 5/22/05 3:45 PM documents, "tube feeding discontinued, chest congested 11 noted, call DR., waiting for the call back. from Doctor, incoming nurse notified, will continue monitor and follow plan of care." 44. According to the nursing progress note the tube feeding was discontinued on 5/22/05 when the resident was observed to have lung congestion. 45. The nursing progress note subsequent to the 5/22/05 3:45 PM did not address the follow up plan of care for the resident's lung congestion and there is no documentation to indicate the physician was notified the resident had a change in condition on 5/22/05 at 3:45 and the tube feeding was discontinued. 46. On 5/23/05. at 6:00AM; the nurse documents "Resident's roommate states resident was "shaking" white frothing liquid secretion noted on mouth." 47. On 5/23/05 at 10:28 AM, the resident was found unresponsive in respiratory distress and had no pulse. Cardiopulmonary resuscitation was initiated, the resident was pronounced dead at a local hospital on 5/23/05 at 10:52AM. 48. Further review of the resident's medical record revealed the medical record did not contain documentation to substantiate the resident had received hemodialysis treatment for the period of 5/16/05 through 5/23/05. The resident's medical record did not contain documentation to 12 indicate the care plan was implemented and hemodialysis treatment was coordinated with a dialysis facility. 49. Interview with the Director of Nursing (DON) and Staff Development Coordinator, a Licensed Practical Nurse on 6/7/05 at 11:30AM and 2:30PM revealed on 5/16/05 a case manager at a local hospital called the facility and informed the admission coordinator the resident would be discharged to the facility that day and dialysis treatment was arranged with a local Dialysis facility. The Director of Nursing stated, the charge nurse called the Dialysis facility on 5/17/05 to obtain a dialysis schedule and was told they would not accept the resident. 50. The DON and staff development coordinator stated, the resident did not have an advanced directive in the medical record so the resident's family was contacted regarding hospice care. The surveyor asked if the physician had recommended hospice care. The DON replied, "No." 51. The DON informed the surveyor she/he has reviewed the resident's (#5) medical record and there is no documentation to indicate the physician was notified that the resident had not received the prescribed hemodialysis treatment. 52. The staff development coordinator stated, it is common facility practice for the desk nurse/charge nurse to notify the doctor of changes, so she assumed the physician was notified. 53. Interview conducted on 6/7/05 at 3:05PM with Licensed Practical Nurse and charge nurse of 5/17/05, revealed the local Dialysis facility was contacted on 5/17/05 to obtain the resident's hemodialysis schedule. A nurse at the Dialysis facility informed him/her the dialysis facility did not have any record of the patient and would not accept a resident who is unresponsive. The nurse stated, later that day (5/17/05) he/she called the resident's family and other dialysis facilities to arrange dialysis treatment for the resident, but they would not accept the resident because the resident's was unresponsive and needed a stretcher during dialysis. 54. The Licensed Practical nurse stated, he/she did not inform the physician that the resident did not received hemodialysis treatment. 55. The Licensed Practical Nurse stated, he/she did not take any further action to ensure the resident received hemodialysis treatment. 56. Interview conducted with the social worker on 6/7/05 in the afternoon revealed on 5/19/05 she/he was informed by a nurse to contact the resident's family to obtain consent for hospice care because the resident had not received dialysis treatments since admission on 5/16/05. The 14 social worker stated, she called the resident's wife and left a message, but the family did not contact the facility. The social worker stated she documented this information in the medical record on 5/20/05. 57. Interview conducted with the Administrator and Administrative Assistant at the Dialysis on 6/8/05 at 1:20PM revealed, the facility has no transfer record for this resident. 58. The Administrative Assistant is responsible for new patient medical records, he/she stated about two weeks ago a case manager at a local hospital facility to inquire if they would accept a patient who is unresponsive and needs to be dialyzed on a stretcher. The case Manager was informed, the facility could not accommodate the patient and recommended the case manager find a nursing home with in- house dialysis services. The administrative assistant stated, there was no other communication with a case manager or other staff from the local hospital. 59. Interview conducted with a case manager at the local hospital on 6/8/05 in the afternoon revealed on 5/13/05 the Dialysis facility’ was contacted to arrange dialysis for resident #5. The case manager who made the dialysis arrangement was not available for interview. The case manager stated, the documentation in the hospital computer did not indicate the medical record was sent to the dialysis facility and the transfer arrangement was confirmed prior to the patient's discharge. 60. The resident's medical record at the Skilled Nursing Facility contains no documentation to substantiate the physician was notified that hemodialysis treatments were not administered to resident #5 for seven (7) days May 16- 23, 2005, as ordered. The facility did not obtain an order to send the resident to the hospital for evaluation and follow-up care when the dialysis treatment was not available at a dialysis facility. The facility did not ensure the physician was aware the resident had a change in condition and that the tube feeding was discontinued by the nursing staff. 61. Based on the foregoing, Azalea Court violated Title 42, Section 483.20(a), Code of Federal Regulations as incorporated by Rule 59A-4.1288, and 59A-4.109(1), Florida Administrative Code, and Sections 400.211(3), 400.215, 400.1034, and 400.147(1) (d), Florida Statutes, herein classified as a Class II deficiency pursuant to Section 400.23(8) (b), Florida Statutes, which carries, in this case, an assessed fine of $2,500.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Azalea Court 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 is attached hereto as Exhibit VAY" CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A, Make factual and legal findings in favor of the Agency on Counts I and II. B. Assess an administrative fine of $5,000.00 against Azalea Court on Counts I and II, Cc. Assess and assign a conditional license status to Azalea Court in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2004). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency 17 for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR 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. elson E. Rodney FL Bar No: 178081 Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52"? Terrace Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 1710 East Tiffany Drive, Suite 100 West Palm Beach, Florida 33407 (U.S. Mail) Jean Lombardi Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) EXHIBIT “A” Conditional License License No. SNF 1198096 Certificate No. Effective date: 06/07/2005 Expiration date:11/30/2005 19

Docket for Case No: 05-003573