OT 7 FUT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . an vs. Case Nos. 2007003901 (Cond.) 2007003883 (Fine) LEESBURG REGIONAL MEDICAL CENTER, INC., d/b/a LRMC NURSING CENTER, 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 LEESBURG REGIONAL MEDICAL CENTER, INC., d/b/a LRMC NURSING CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120,57 Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing March 30 2007 and impose an administrative fine in the amount of $37,500.00, and a survey fee in the amount of $6,000.00, based upon Respondent being cited for three State Class I deficiencies. JURISDICTION AND VENUE lL The Agency has jurisdiction pursuant to §§ 120.60 and 400,062, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207, EXHIBIT A 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 IV, Subtitle C (as amended), Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4, Respondent operates a 120-bed nursing home, located at 700 North Palmetto Street, Leesburg, FL 34748, and is licensed as a skilled nursing facility license number 12990961. 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COMMON FACTUAL ALLEGATIONS 6. That on or about March 29, 2007, the Agency completed an Annual Survey at Respondent’s facility. 7. ‘That the Petitioner’s representative reviewed the Respondent’s records, including medical records, relating to resident number twenty-two (22) during the survey and noted the following: a. That the resident was admitted on January 12, 2007; b. That the resident’s diagnoses included diabetes mellitus; c. A physician’s order dated January 12, 2007 required that the resident’s blood sugar levels (hereinafter “BS”) to be performed before meals and at bedtime; d. Included in the admission orders dated January 12, 2007 was a protocol for the nursing staff to follow in the event the resident's blood sugar was low enough to warrant intervention; e. The order dated January 12, 2007 was listed as number three (3) of page two (2) on the Physician Order Sheet (hereinafter “POS”) and appeared as: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (50 inject 1 amp) f. The medical record revealed the following BS for the resident on January 16. and 17, 2007 along with the annotated intervention performed by the nurse: 1/16/07 3:00 PM-11:00 PM Nurse 1635=65, Glass of Apple juice .1740=97, No interventions 2026=66, Glass of Apple juice 11:00 PM -7:00 AM Nurse 2330=43, Two glasses of apple juices 01/17/07 : : 0008=31, Two apple juices and two orange juices 0021=42, Health Shake and 3 instant oral glucose 0058=30, No interventions documented 0132=33, Attempted to start IV 0143=38, Resident cardiac arrest, expired g. That there existed no indication in the medical record review that the resident’s physician was notified of the resident’s low BS; ) h. That the interventions administered by the Respondent’s nurse are in clear conflict with the physician protocol, 8. That the Petitioner’s representative interviewed, on March 29, 2007, the Respondent’s nurse that served on the 11:00 PM to 7:00 AM shift for resident number twenty-two who . indicated ".. [D]id not do the protocol because the health shakes usually work" and, when asked why the physician was not called, stated "I never call the physicians but I would just send-the’ tesidents to the Emergency Room if needed,” 9. That the Petitioner’s representative interviewed the physician of resident number twenty- two (22) on March 29, 2007 who indicated that he would have expected a telephone call from the Respondent’s 11:00 PM to 7:00 AM nurse for this resident concerning the resident’s low BS but did not get one. 10. That the Petitioner’s representative interviewed the Respondent’s director of nursing on March 29, 2007 regarding the death of resident number twenty-two who indicated that the medical record, an unexpected death, was not reviewed by the Respondent as part of its quality improvement program. 11. That the Petitioner’s representative observed the Respondent’s administration of medications to residents on March 26, 2007, interviewed the medication nurse administering medications, and reviewed the Respondent’s records regarding residents, both current and former, and noted the following: a. Resident number fifteen (15): i, At 8:35 AM, the prescribed medication, Zyvox, an antibiotic to treat the resident’s pneumonia, was not administered to the resident; il, The physician’s order for the resident to be administered Zyvox to the resident was ordered on March 23, 2007 at 10:00 PM; iii. The medication nurse for this resident stated that the medication was not available from pharmacy yet and that the resident had not received any of the prescribed doses as of yet; iv. The medication nurse ultimately indicated that she called the pharmacy and was told they would have the Zyvox for the resident’s 8:00 PM dose on March 26, 2007. b. Resident number fourteen (14): i. ii. iv. That at 8:20 AM, the medication nurse for this resident flipped the Medication Administration Record (hereinafter “MAR”) over and wrote "Med out of stock, has reorder"; - The medication nurse indicated that she did not administer the resident’s | prescribed Lactinex, a medication addressing diarrhea, as the facility does not have the pill form as ordered and that the resident will not take powdered form; The resident’s MAR indicated that the resident had not been administered the prescribed Lactinex for the previous fifteen (15) days; The resident’s MAR was annotated on March 21, 2007 at noon by a nurse - "Has been reordered many times." Resident number thirty-one (31): i, ii. The resident had been prescribed a hypoglycemic protocol on March 13, 20/07 which provided as follows: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (S0 inject 1 amp) That recorded BS levels for the resident as recorded for the month of March 2007 documented the following: March 15, BS = 71; March 17, BS = 52; March 19, BS= 79; March 25, BS = 68; and March 28, BS = 67; That the resident’s MAR did not include any indicia that the prescribed hypoglycemia protocol and its interventions were administered or followed. Resident number thirty-five (35): i. li. iii. iv. The resident was admitted on February 11, 2007 at 6:30 PM; The resident’s MAR indicated physician’s orders for Rocephin, an antibiotic, Paxil, a medication for depression, and Colace, a stool softener; The MAR reflected that the resident’s Rocephin was not available or administered to the resident on February 12 and 13, 2007, that the resident’s prescribed Paxil was not available or administered on February 12, 2007, and that the resident’s Colace was not available or administered on February 13, 2007; The MAR reflected that no prescribed medications were administered to the resident until February 13, 2007, to days following the resident’s admission. Resident number thirty-our (34): i, ii. ill. The resident was admitted to the facility on February 11, 2007 at 5:00 PM; The resident’s MAR reflected prescriptions for : Coreg, for blood pressure; Zocor, for cholesterol; Amaryl, for diabetes; Evista, to address osteoporosis; Avandia, for diabetes; Zoloft, for depression; and Colace, a stool softener; . The MAR reflected that the resident’s Coreg, and Zocor, were unavailable and not administered on February 11, 2007; The MAR reflected that the resident’s Amaryl, Evista, and Avandia were not available and not administered on February 12, 2007; vi, The MAR reflected that the resident’s Colace was not available and not administered on February 13, 2007; The MAR reflected that none of the resident’s prescribed medications were available and administered to the resident until the 8:00 PM administration of medications on February 12, 2007, in excess of twenty- four (24) hours after the resident’s admission to the Respondent facility. Resident number thirty-three (33): _ i. i. iii. Iv. The resident was admitted to the facility February 3, 2007 at 7:00 PM.; The resident’s MAR reflected prescriptions for Calcium, a supplement, Seroquel, for psychotic disorders, and Namenda, for Alzheimer’s disease; The MAR reflected that the resident’s Calcium was not available and not administered on February 13, 2007; The MAR reflects that the resident’s Seroquel was not available or administered on February 13, 2007; The MAR reflects that the resident’s Namenda was not available or administered on February 13, 2007. Resident number twenty-eight (28): i, li. iil. The resident was admitted on July 25, 2005; The resident’s diagnoses included diabetes mellitus, schizophrenia, hypertension, and psychotic disorder; The March 2007 MAR reflected physician’s orders for the resident’s blood sugar to be checked by accucheck before ineals and at bedtime; . Physician’s orders for insulin coverage on a sliding scale with Novolin R Insulin as follows: Blood Sugar 200-249 give 2 units Blood Sugar 250-299 give 4 units Blood Sugar 300-349 give 6 units v. The March 2007 MAR revealed the following blood sugars recorded at 200 and above; There was no documentation on the MAR that insulin coverage was given at these times: 3/1 @ 6:00 AM of 209 3/4 @ 11:30 AM of 207 3/10 @ 11:30 AM of 205 3/14. @ 11:30 AM of 225 3/18 @ 11:30 AM of 234 3/20 @ 11:30 AM of 219 4:30 PM of 213 8:00 PM of 245 3/24 = @ 11:30 AM of 260 3/25 @ 11:30 AM of 230 3/26 @ 11:30 AM of 210 3/27 @ 8:00 PM of 227 vi. The MAR and resident records did not reflect that the insulin coverage prescribed by the physician in the sliding scale was administered to the resident as would be required under the physician’s protocol; vii. The Respondent’s unit manager indicated on March 29, 2007 that there was no proof whether nurses gave the insulin or not on those dates 5 viii. No other place where the medication administration was typically charted was produced, nor could such annotations be found. Resident number thirty (30): i. The resident was readmitted on March 1 , 2007; ii, The resident’s diagnoses included insulin dependent diabetes mellitus, cardio vascular accident, dysphagia and decubitus ulcer; iii. vi. vii. The resident’s MAR included orders for blood sugar levels to be checked by accucheck before meals and at bedtime: Physician’s orders directed sliding scale insulin coverage with Novolin R Tnsulin as follows: Blood Sugar 151-200 give 2 units Blood Sugar 201-250 give 4 units Blood Sugar 251-300 give 6 units The March 2007 MAR recorded the following blood sugars recorded at 151 and above: 3/3, @ 11:30 AM of 151 3/4 @ 4:30 PM of 172 3/7 @8 PM of 151 3/8 @ 4:30 PM of 210 3/9 @ 4:30 PM of 232 3/13 @ 8 PM of 192 3/16 @ 8 PM of 173 3/19 @ 4:30 PM of 174 3/20 @ 4:30 PM of 218 3/22 @ 4:30 PM of 232 3/25 @ 11:30 AM of 168 3/26 @ 11:30 AM of 161 The MAR and resident records did not reflect that the insulin coverage prescribed by the physician in the sliding scale was administered to the resident as would be required under the physician’s protocol; The Respondent’s unit manager indicated on March 29, 2007 that there was no other place where the medication administration was typically charted or was further documentation of insulin medication administration provided. Resident number thirty-two (32): i. The resident was admitted February 4, 2007 at 7:30 PM; il. Upon admission. the resident’s physician ordered Preservision Softgels,a vitamin and mineral supplement, take 1 capsule by mouth 2 times daily; iii. The resident’s MAR revealed the medication not given for either dose on February 5, 2007, and noted the medication was on order from the pharmacy; iv. The resident’s physician ordered on F ebruary 5, 2007 Albuterol, a broncodilator, .83 mg/ml solution, and Ipratropium BR, for symptoms of bronchitis and emphysema, .02% solution, use 1 unit of each in updraft every 8 hours; v. The resident’s February 2007 MAR does not reflect that these two prescribed solutions were administered on the scheduled 11:00 PM administration times for the following dates: February 5, 9, 13, 15, 16, 17, 18, 19, 20, 22, 23, and 24, 2007; vi. The resident’s MAR contained no documentation or nursing notes explaining or justifying the failure to administer the medications as ordered; vii, The Respondent’s director of nursing indicated on March 30, 2007 that it appeared that the resident’s Albuterol was not administered on those dates and no further documentation was produced to reflect why the medication, was not administered, j. Resident number seven (7): i. The resident was admitted on March 13, 2007; ii, That the resident’s diagnoses included esophageal cancer, status post il. Vi. vii. viii. ix. xi. xii. radiation treatment and chemotherapy; Physician’s orders of March 13, 2007 are annotated on the MAR for Morphine Sulfate 15 mg Tab SA, substitute for MS Contin 15 mg SA, take 3 tablets every 8 hours; The resident’s MAR reflects that on March 18, 20/07 the resident's 10 PM dose was omitted; The MAR annotated as to-the failure to administer the medication that "MS Contin was on order."; The resident’s MAR reflects that on March 19, 2007, the resident’s 6:00 | AM and 2:00 PM were not administered; The Mar was annotated reflecting the reason the 2:00 PM dose was not administered was "not available from the pharmacy."; There was no explanation documented by Respondent’s nursing staff for the omission of the 6:00 AM dose on March 19, 2007; The MAR documented physician orders dated March 13, 2007 for Nystatin 100,000 U/ml suspension, an antifungal, swish & swallow, 1 teaspoon 4 times daily; The MAR reflected that the noon, 4:00 PM, and 8:00 PM doses were not administered to the resident on March 25 , 2007; Documented on the resident’s MAR for the noon and 4:00 PM administration was "not available from pharmacy."; There was no explanation documented by nursing for the omission of the 8:00 PM dosage; xiii. The Respondent’s director of nursing indicated on March 28, 2007 that no further documentation could be provided to explain the omission of the resident’s medications. COUNT I 12. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11) as if fully set forth herein. 13. That pursuant to Florida law, all licensees of nursing homes facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with tules as adopted by the agency. § 400.022(1)(), Florida Statutes (2006). 14. That Florida law provides the following: “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 ofa registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the 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(b), Florida Statutes (2006). 15. That based upon observation, the review of records, and interview, the Respondent failed to ensure the resident's right to receive adequate and appropriate health care by failing to provide care and services in accordance with the resident's plan of care for eleven (11) of thirty-eight (38) residents reviewed. 16. That for each of the resident’s referenced, physician’s orders, a pivotal part of the resident’s plan of care, were not followed by the Respondent in its failure to provide and administer prescribed medications. 17. That each prescribed medication must be provided and administered in accord with physician’s orders, and the failure to provide physician prescribed care and services created a serious and immediate threat to the health and wellbeing of the residents as illustrated by failures, including but not limited to, the provision of medications pivotal in the regulation of disease processes including diabetes, emphysema, mental illness and pain management 18. That inclusive in these failures are the Respondent’s nursing staff failing to provide medication administration as ordered and in at least one resident, the Respondent’s nurse ‘substituting her judgment as to appropriate diabetic interventions for that of the residents physician. 19, The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 20. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 12, 2007. 13 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $12,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT It 21. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11) as if fully set forth herein. . 22. That pursuant to Florida law, all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift. R. 59A-4.107(5), Florida Administrative Code. 23. That based upon observation, the review of records, and interview, the Respondent facility failed to administer physician ordered medications and further failed to consistently record the reason for non-compliance in the resident’s record. 24. That a threat to the health and safety of a patient is inherent in not administering his or her medication as prescribed. The conditions or symptoms for which the medication was prescribed remain unaddressed and could worsen. In addition, health care providers, including primary care physicians, consulting physicians and even emergency medical services personnel, oftentimes rely upon facility medication records in making decisions about a patient’s care and treatment. 25. That when medications are not administered, and the cause for such failure to administer is unknown, treatment providers lack necessary information to determine future medication prescriptive decisions, 26. That where the Respondent fails to obtain medications for administration, it has violated the requirement that physician’s orders be followed. 14 27. ‘That these failures create a serious and immediate threat to the health and well-being of the residents and were patterned throughout the facility. 28, The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 29. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 12, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $12,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). . COUNT Il 30. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11) as if fully set forth herein 31. That pursuant to Florida law, an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. § 400.102(1)(a), Florida Statutes (2006). 32, That based upon the review of records and interview, the Respondent intentionally or negligently failed to implement policies and procedures to prevent neglect by failing to ensure care and services to provide physician ordered medications and prescribed care for residents and failed to timely respond to resident needs when assistance is requested by residents. 33. That the Petitioner’s representative interviewed resident number nine (9) on March 26, 2007 who indicated that about a week prior the resident had an incontinent episode (bowel) in bed and it took forty-five (45) minutes to an hour to be cleaned, and that the resident is aware when the need to have a bowel movement arises, but had to wait and had the incontinent episode ' while waiting on the staff to assist. 34. That the Petitioner’s representative interviewed residents numbered nine (9), twenty-three (23), thirty-nine (39), forty-two (42), forty-three (43), and forty-four (44) en masse on March 27, 2007 each of whom reported the following: a. That they had experienced an incontinent episode within the past three (3) months; That prior to the incontinent episode, the residents had activate their call lights; That the call light was responded to and turned off by the responding staff member; That the responding staff member informed the residents that the staff member was not assigned to the resident and that the resident would have to await assistance from the staff member assigned to the resident; That the residents wait for assistance by their assigned staff member for a period of forty-five (45) minutes or more, necessitating the incontinent episode; ‘That the residents’ later learned that their assigned staff member did not assist the resident as the staff member was on break or had not been told of the residents’ requests for assistance. 35. That the Petitioner’s representative interviewed Respondent’s certified nursing assistant number one (1) on March 27, 2007 who indicated as follows: a. That though nursing assistants are assigned room numbers to cover on their shift, everyone is supposed to assist if a nursing assistant goes on a break or if a resident call bell/light goes on when you are walking down the hall; b. That you never know why that light is on so you should answer it; c. That her assigned resident's have brought to her attention that they have been made to wait for care to be provided while she has been on a break or busy attending another resident; . d. That she informed nurses when this occurs. 36. That the Petitioner’s representative interviewed Respondent’s certified nursing assistant number two (2) on March 27, 2007 who indicated as follows; a. That regarding call bells/lights, her assigned resident's have reported to her that they have been made to wait for care to be provided while she has been on a break or busy attending another resident; | b. That nurse's are made aware of when this occurs. 37. That the Petitioner’s representative reviewed the Resident Council minutes for March 20, 2007 which reflected that call lights are "not answered in a timely manner or they (staff) will say I'll get your aid or I'll be right back and not come back": 38. That the Petitioner’s representative reviewed the Respondent’s resident Grievance Log which was annotated on March 20, 2007 for the North, West and South wings that "Patient state that the call lights don't get answered in a timely manner and when the aides come they say they'll be right back and don't come back," and the “F ollow-up section” indicated that “Referred to charge nurse for follow up timing of CNAs to answer call lights". 17 39. That the Petitioner’s representative reviewed the facility's Nursing Standards Manual and noted that in the PREVENTION AND REPORTING OF RESIDENT ABUSE section under Purpose the Respondent defines Neglect as "The failure or omission on the part of the caregiver to provide care, supervision and services necessary to maintain the physician and mental health of vulnerable adult, including but not limited to, food, clothing, medicine, shelter, supervision, _ and medical services, that a prudent person would consider essential for the well-being of a vulnerable adult. This term also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult form abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical harm or psychological injury or a substantial risk of death. " 40. That these facts reflect intentional or negligent acts of Respondent through its agents and employees that effect the health and safety of residents in the staff’s failure to administer medications as ordered, the staff administration of interventions in contradiction of physician orders, the staff’s failure to ensure prescribed medications are available for and administered to residents as ordered, and the failure to render services to residents in response to call bells where the resident is in need of assistance for activities of daily living. 41. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 42. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 12, 2007. 18 WHEREFORE, the Agency intends to impose an administrative fine in the amount of $12,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT IV 43. The Agency re-alleges and incorporates Counts I through IIL of this Complaint as if fully set forth herein. 44. Respondent has been cited for three State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400,19(3), Florida Statutes (2006). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of $6,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2006). COUNT V 45. The Agency re-alleges and incorporates Counts I through II as if fully set forth herein. 46. Based upon Respondent’s three cited State Class I 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)(a), Florida Statutes (2006). WHEREFORE, the Agency intends to assi gn a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2006) commencing March 30, 2007. Respectfully submitted this “B day of April, 2007. ay s J. Walsh, I, Esquire la? Bar. No. 566365 Agéncy for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Florida Statutes (2006), 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 ari ght to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. 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, (85 0) 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 THEREBY CERTIFY that a true and correct copy of the foregoing has beemserved by USS. Certified Mail, Retum Receipt No: 7004 1350 0004 2776 0628 on April Z S 2007 to: Ron Hollerand, Administrator, LRMC Nursing Center, 700 North Palm St., Leesburg, FL 34748 and by U.S. Mail to Phillip Braun, Esq., Reg. Agent., 600 Bast i ‘enue, Leesburg, FL 34748. Copies furnished to: James Wilson, Administrator Phillip Braun, Esq. LRMC Nursing Center Registered Agent. 700 North Palmetto St. 600 East Dixie Avenue Leesburg, FL 34748 Leesburg, FL 34748 (U.S. Certified Mail) (U.S. Mail) Kriste Mennella Thomas J. Walsh, II, Esquire Field Office Manager Senior Attorney 14101 NW Hwy 441 Agency for Health Care Admin, Suite #800 525 Mirror Lake Dr, 330G Alachua, FL 32615 St. Petersburg, Florida 33701 (U.S. Mail) (nteroffice) EXHIBIT B PRINTED: 04/05/2007 FORM APPROVED eney for Flealth Care Administration TEMENT OF DEFICIENCIES PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY {X2) MULTIPLE CONSTRUCTION COMPLETED 33508 03/30/2007 PROVIDER OR SUPPLIER ViC NURSING CENTER STREET ADORESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 1D SUMMARY STATEMENT OF DEFICIENCIES EFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL AG REGULATORY OR LSC IDENTIFYING INFORMATION) 1000) INITIAL COMMENTS This plan of correction constitutes our credible allegation of compliance with licensure Tequirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing . contained herein shall be construed as an admission that the facility violated any federal or state Tegulation or failed to follow any applicable standard of care, An unannounced Licensure survey was conducted on March 26, 2007 - March 30, 2007, Deficiencies were identified. The facility is not in compliance with Chapter 400, Part il FS and 59A-4 FAC. Compliance with state and federal nursing home regulatory provisions is monitored separately as of July 1, 2005. This survey reflects only those noted deficient practices under state statutes and regulations : The following identified residents #22, #33, #35, #34, and #15, were discharge chart reviews. Resident #28, #30, and #3 Lhave received subsequent accuchecks as ordered, documented on the new diabetic MAR, and existing hypoglycemic protocols followed as per physician orders. ~~“ Review of ordered medications Or Resident #7, #14, #32, and #15 have determined that all medications are -available for administration from the assigned medication cart, 054! 59A-4.107(5), F:A.C. Follow Physician Orders 3=K 59A-4.107(5) All physician orders shall be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift. Ny: Based observation, record review, and staff interviews the facility failed for 11 of 38 residents (#22,28,30, $2,35,34,33,14,15,7, and 31) to administer physician ordered medications. Failure to provide physician prescribed Medications Created a serious and immediate threat to the health and welling of the residents, All residents have the potential to be affected. ‘ Findings: 1, Review of the medical record for Resident #22 revealed the resident was admitted on 01/12/2007 with a diagnosis of Diabetes Mellitus. On 1/12/2007 bloods sugar levels (BS) were ordered to be performed before meals and at bedtime. Included in the admission orders dated 112/07 wey @ protocol for the nursing staff to i soa0-o0pT 7 : Initiated training 3/30/07 for all nursing staff to include PRN staff on existing medication administration, existing hypoglycemic protocol, customer service, behavior standards; physician notification, (X8) DATE 'RY DIRECZOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE ‘ Yh . a f {/ need NONW11 if continuatién shegt' 1 of 40 | EXHIBIT B gency for Health Care Administration ATEMENT OF DEFICIENCIES. D PLAN OF CORRECTION Nn, MC NURSING CENTER Xa) ID SUMMARY STATEMENT OF DEFICIENCIES "REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) N 054] Continued From page- 1 (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 33508 PROVIDER OR SUPPLIER follow in the event the resident's blood sugar was low enough to warrant intervention. The order dated 01/12/07 was listed as #3 of page two on the Physician Order Sheet (POS) and appeared as: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject 4% amp) BS (50 inject 1 amp) Review of the medical record for resident #22 revealed the following BS for the resident on 01/16-17/07 with intervention performed by the nurse, 1/16/07 3:00 PM-11:00 PM Nurse 1635=65, Glass of Apple juice 1740=97, No interventions 2026-66, Glass. of Apple juice 11:00 PM -7:00 AM Nurse (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING N 054. PRINTED: 04/05/2007 FORM APPROVED {X8) DATE SURVEY COMPLETED STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) This plan of correction constitutes our credible allegation of compliance with licensure requirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations, Nothing contained herein shall be construed as an admission that the facility violated any federal or state regulation or failed to fallow any applicable standard of care. Emergency Drug Kit use and Medication errors by DON, | Pharmacy Consultant and Nurse Consultant. Training completed on 4/11/07. New staff or staff returning from LOA will receive training ongoing. The nursing secretary will . provide all agency nurses handouts , in regards to mandatory training prior to working with residents. To obtain medications in a timely manner, all new and refill medications. will be faxed by.the 2 03/30/2007 {X5) COMPLETE DATE =43; glasses of apple juices 01/17/07 0008=31, Two apple juices and two orange juices 0021=42, Health Shake and 3 instant oral glucose : 0058=30, No interventions documented 0132=33, Attempted to start IV 0143=38, Resident cardiac arrest, expired. Medical record review did not reveal that the physician was notified of the low BS. Interview with the 11:00 PM to 7:00 AM nurse on 3/29/2007 at 9:15 AM revealed "Did not do the protocol because the health shakes usually work". When asked why the physician was not called the nurse stated that "I never call the physicians but | would just sent the residents to the Emergency Room if needed." Form 3020-0001 = FORM } nurse to the pharmacy followed by a phone call. The courier will be contacted to pick up and deliver the “medications ordered as of 4/2/07. / All medication will be supplied in a | timely manner such that no resident | will be subjected to discomfort or his/her health and safety compromised. If pharmacy is unable to mest the above standard, the SNF Administrator will then be notified. The SNF Administrator will then notify pharmacy management personnel to insure compliance. NONW11 If continuation sheet 2 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for’Health Care Administration \TEMENT OF DEFICIENCIES > PLAN OF CORRECTION (X3) DATE SURVEY X1) PROVIDER/SUP (X1) PROVIDER/SUPPLIER/CLIA COMPLETED (X2) MULTIPLE GONSTRUCTION IDENTIFICATION NUMBER: 33508 03/30/2007 Ww «MC NURSING CENTER . PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N.054! Continued From page 2 This plan of correction constitutes our credible allegation of compliance with licensure requitements. _ This plan of correction is beitig submitted pursuant to Interview with the resident's physician by "the applicable Federal and state regulations. Nothing telephone on 03/29/2007 at 9:00 AM revealed contained herein shall be construed as an admission that that he would have expected a telephone call the facility violated any federal or state regulation or from the 11:00 PM to 7:00 AM nurse for this failed to follow any applicable standard of care, resident concerning the low BS but | did not get : one. Inventory of the Emergency Drug ; Kits (maintained on site) reviewed Interview with the Director of Nursing (DON) on by the Medical Director for 03/29/2007 at 10:00 AM revealed that the medical record (unexpected death) was not completeness on 4/9/07. The EDK reviewed as part of the quality improvement Kits were changed on 4/10/07 to program. . include medications that likely will meet the needs of first dosing of antibiotics, pain medications and widely prescribed emergency 2. Observation of Medication pass of resident #15 on 03/26/07 at 8:35 AM, revealed the medication Zyvox (an antibiotic to treat the resident pneumonia) was not given, the medication nurse medications, and placed in service, for this resident, stated the medication. was not A complete audit of all medication available from pharmacy yet and the resident has carts was done to ensure that every not received any doses yet medication on the MAR was present ' eview of thie Physicians orders reveals the = ithe aedivation cart and/or i Zyvox for resident #15 was ordered 03/23/07 at obtained on 3/30/07. Daily random 10 PM. Interview 03/26/2007 at 8:35 AM with audits of medication availability in Medication nurse reveals she called the i at a minimum of 5 pharmacy and was told they would have the assigned cart (at a Zyvox for the 8 PM dose 03/26/07. residents per wing) will continue until compliance is sustained, by unit 3. Observation of Medication pass for resident of manager or designee. Results will be #14 on 03/26 07 at 8:20 AM revealed that the reviewed in daily morning standup medication nurse for this resident flipped the Medication Administration Record (MAR) over and wrote "Med out of stock ,has reorder’. The medication nurse for resident #14 was meeting, weekly Standard of Care meeting, and the Monthly Quality Improvement Committee with questioned by this surveyor at this time. The appropriate actions taken, medication nurse stated that she did not give the A new Diabetic Medication Lactinex dose as they do not have the pill form as Administration Record was ordered and that the resident will not take powdered form. Review of the MAR indicates the =orm 3020-0001 FORM 6899 NONW11 If continuation sheet 3 of 40 implemented 3/30/07 to include the ency for Health Care Administration sTEMENT OF DEFICIENCIES ) PLAN OF CORRECTION A /PROVIDER OR SUPPLIER ‘MC NURSING CENTER <4) 1D REFIX TAG \.054/ -Continued.From-page-3-- - wee ne 4 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 33508 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) resident has not had Lactinex for 15 days. Record review revealed that on 3/21/06 12:00 noon the nurse wrote on back of MAR "Has been reordered many times." 4. Record review for resident #31 revealed that the resident # 31 has a hypoglycemic protocol ordered on 03/13 /07, it reads as follows: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (50 inject 1 amp) Review of resident #31's blood sugars for the month of March revealed that on 03/15/07 resident #31 had a Blood Sugar (BS) of 71, on 03/17/07 a BS of 52, on 03/19/07 a BS of 79, on 03/25/07 a BS of 68 and on 03/28/07 a BS of 67. Further review of the MAR in the Hypoglycemia _.[ protocol section revealed no entries to indicate | -the-protece!had-been-followed- PRINTED: 04/05/2007 FORM APPROVED (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 ID PROVIDER'S PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) : N054.. - “This plan of correction constitutes our credible ~ ~~ allegation of compliance with licensure Tequirements. _ This plat of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing” contained herein shall be construed as an-admission that the facility violated any federal or siate tegulation or failed:to follow any applicable standard of care, accuchecks result, sliding scale dose as indicated, site of administration as indicated and hypoglycemic protocol to be followed. All routine accuchecks will be audited by the Nurse consultant and/or designee for correct implementation of sliding” scale and hypoglycemic protocol. Results will be reviewed in daily morning standup meeting, weekly Standard of Care Meeting, and ‘implementation of sliding scale and _.-. {hypoglycemic protocol. {X3) DATE SURVEY COMPLETED 03/30/2007 (X5)- COMPLETE DATE 5. Closed record review for resident #35 revealed the resident was admitted 02/11/07 at 6:30 PM. _| Review of the MAR indicated an order for Rocephin (an antibiotic) not available 02/12/07 and 2/13/07 , Paxil (used to treat depression) not available on 02/12/07, Colace (stool softener) not available 02/13/07. No medications were on the MAR were signed off as given until 02/13/07. 6. Closed record review for resident #34 revealed the resident was admitted to the facility on 02/11/07 at 5:00 PM. Review of the MAR revealed Coreg (for blood pressure) and Zocor (for cholesterol) not available 2/11/07, Amaryl (for Diabetes) not available 02/12/07, Evista (to prevent Osteoporosis), Avandia (for Diabetes), “orm 3020-0001 FORM ) 6899 All audits will be submitted weekly by the DON and/or designee to the Standards of Care Committee for review and determination of compliance. Pertinent issues will be forwarded to the Risk Committee. Reassessment of need for monitor frequency will be evaluated based on compliance. All audits & recommendations will be forwarded to the Quality/Risk committee for assessment and actions. NONW11 Wh loz If continuation sheet 4 of 40 - PRINTED: 04/05/2007 FORM APPROVED gency for Health Care Administration STEMENT OF DEFICIENCIES X1) PROVIDER/SUPPLIER/CLIA STRUCTION (X3) DATE SURVEY D PLAN OF CORRECTION 1) IDENTIFICATION NUMBER: (X2) MULTIPLE GONSTRUGTIO COMPLETED . 33508 ; 03/30/2007 N PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE : 700 NORTH PALMETTO ST MC NURSING CENTER LEESBURG, FL 34748 x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N-064)-Centinued-From page 4—-..- - - --—~ f NOB4 = ‘this plan Of coivection Consiinites a Geaible j i allegation of compliance with licensure requirements. Zoloft (for depression), also not available. Colace ‘This plan of correction is being submitted pursuant to {stool softener ) not available on o2/ 13/07. Further the applicable Federal and state regulations. Nothing review of the MAR reveals that resident #34 did contained herein shall be construed as an admission that not receive any medications until their 8:00 PM the facility violated any federal or state regulation or dose on 02/12 107. failed to follow any applicable standard of care. 7. Closed record review for resident #33 revealed the resident was admitted to the facility 02/03/07 at 7:00 PM. Review of the MAR revealed a Calcium (a supplement) was not available 02/13/07, Seroquel (for psychotic disorders) was not available 2/13/07, Namenda (Alzheimers treatment) was not available on 02/13/07. 8. Record review revealed Resident #28 was admitted on 7/25/05 with diagnosis including Diabetes Mellitus, Schizophrenia, Hypertension, and Psychotic Disorder. Review of the March 2007 Medication Administration Record (MAR) revealed blood sugar (accucheck) before meals and at bedtime. The resident had physician —{ olders for Sliding Scale Insulin coveragewith =| | elin-R-Instlin-as-fotlows: oe Blood Sugar 200-249 give 2 units Blood Sugar 250-299 give 4 units Blood Sugar 300-349 give 6 units Review of the March 2007 MAR revealed the following blood sugars recorded at 200 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/1 @6 AM of 209 3/4 = @ 11:30 AM of 207 3/10 = @ 11:30 AM of 205 3/14. @ 11:30 AM of 225 3/18 @ 11:30 AM of 234 3/20) = @ 11:30. AM of 219 4:30: PM of 213 Form 3020-0001 : FORM ean9 NONW11 lfcontinuation sheet 5 of 40 ) PRINTED: 04/05/2007 FORM APPROVED ency for-Heailth Care Administration \TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X3) DATE SURVEY Xt) PROVIDER/SUPPLIER/CLI a) ‘A COMPLETED (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING 33508 03/30/2007 a STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 PROVIDER OR SUPPLIER {MC NURSING CENTER «1D SUMMARY STATEMENT OF DEFICIENCIES REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PROVIDER'S PLAN OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) \-054.-Continued-From-page §--—-—- - -—. ... . . | .NO54... 8:00 PM of 245 3/24 = =@ 11:30 AM of 260 3/25. = @ 11:30 AM of 230 3/26 = =@ 11:30 AM of 210 3/27) @ 8 PMof 227 ~~ ~This plan of corretion coristitutes our eredible” ~ ~~ | allegation of compliance with licensure Tequirements. This plan of correction is being submitted pursuant to “thé. applicable Federal and state Tegulations: Nothing Contained herein shall be construed as an admission that the facility violated any federal or state regulation or failed to follow any applicable standard of care, In an interview with the Unit Manager on 3/29/07 at 12:10 PM, it was stated there was no proof whether nurses gave the insulin or not on those dates. The Unit Manager confirmed that there was no other place where the medication administration was typically charted, ‘8. Record review revealed Resident #30 was readmitted on 3/1/07 with diagnosis including, Insulin Dependent Diabetes Mellitus (IDDM), _| CVA, Dysphagia and Decubitus. Review of the }] March 2007 MAR revealed blood sugar (accucheck) before meals and at bedtime. The resident had physician orders for Sliding Scale Insulin coverage with Novolin R Insulin as follows: —} Biood-Sugar454-206 give units - | Blood Sugar 201-250 give 4 units Blood Sugar 251-300 give 6 units Review of the March 2007 MAR revealed the following blood sugars recorded at 151 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/3 @ 11:30 AM of 151 3/4 @ 4:30 PM of 172 3/7 @8 PMof 151 3/8 @ 4:30 PM of 210 3/9 @ 4:30 PM of 232 3/13 @ 8 PM of 192 3/16 @ 8 PM of 173 3/19 @ 4:30 PM of 174 3/20 @ 4:30 PM of 218 ‘orm 3020-0004 FORM e899 NONW11 if continuation sheet 6 of 40 j i PRINTED: 04/05/2007 FORM APPROVED ency for‘Health Care Administration \TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED. {X1) PROVIDER/SUPPLIERICLIA {X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING 33508 03/30/2007 Me. PROVIDER OR SUPPLIER ‘MC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE . DEFICIENCY) N-054 -Continued-From-page Bee ee ee ee N54... LL ‘This-plan of correction-constitutes-our credible. —- -.- —.— — | allegation of compliance with licensurt requirements, 3/22 @ 4:30 PM of 232 This plan of correction is being submitted pursuant to 3/25 @ 11:30 AM of 168 the applicable Federal and state regulations. Nothing 3/26 @ 41:30 AM of 161 contained herein shall be construed as an admission that , the facility violated any federal or state regulation or . ay . _* failed to follow any applicable stendard of care, Interview with the Unit Manager on 3/30/07 at ce Se 1:40 PM revealed no further documentation of ~ insulin medication administration could be provided. 10. Record review revealed Resident #32 was admitted 2/4/07 at 7:30 PM, with physician medication orders for Preservision Softgels, take 1 capsule by mouth 2 times daily. Review of the MAR revealed the medication not given for either dose on 2/6/07, and on order from the pharmacy. Physician orders 2/5/07 were documented for Resident #32 for Albuterol .83 mg/ml solution and Ipratropium BR .02% solution, use 1 unit of each in updraft every 8 hours. Review of the February | 2007 MAR tevealed the medications were not. __ | signed offas administered, on the following dates for the 11 PM dose: 2/5, 2/9, 2/13, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/22, 2/23 and 2/24/07, There was no explanation documented by nursing on the MAR as to why the doses were omitted. In interview with the Director of Nurses (DON) at 1:40 PM on 3/30/07, it was stated that it looked like Albuterol was omitted on those dates. No further documentation was provided. 11. Record review revealed Resident #7 was admitted on 3/13/07 with diagnosis of Esophageal Cancer, Status Post Radiation Treatment & Chemotherapy. Review of the MAR revealed physician orders on 3/13/07 for Morphine Sulfate 15 mg Tab SA, substitute for MS Contin 15 mg Form 3020-0001 FORM . e289 NONW11 lf continuation sheet 7 of 40 ) PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration -TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X38) DATE SURVEY 1 1D P| y {X1) PROVIDERISUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 4 IPROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST MC NURSING CENTER LEESBURG, FL. 34748 4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (%5) EFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 1-054) Continued Frompage7—- — —- —.- - . . -}.nos4__ This plarr of correction constitilés ott credible” "> | : allegation of compliance with li ir . SA, take 3 tablets every 8 hours. On 3/18/07 the This plan of conection is being sabritiel ern resident's 10 PM dose was omitted. The reason the applicable Federal and state regulations. Nothing documented by nursing on the MAR was the "MS contained herein shall be construed as an admission that Contin was on order." On 3/19/07 the resident's acai Violated Srecera oe ate regulation or 6 AM and 2 PM doses were omitted. The reason , Y Apphcable standard of care, documented by nursing on the MAR for omission of the 2 PM dose, was the medication was "not available from the pharmacy." There was no explanation documented by nursing for the omission of the 6 AM dose on 3/19/07, Continued review of the MAR documented physician orders dated 3/13/07, for Nystatin 100,000 U/ml suspension, swish & swallow, 1 teaspoon 4 times daily. On 3/25/07 the 12 noon, 4 PM, and 8 PM doses were omitted. The reason documented on the MAR for the omission at 12 noon and 4 PM was the med "not available from pharmacy." There was no explanation documented by nursing for the omission of the 8 PM dose. . provided for the omission of resident #7's medications. Class | Pattern . Correction Date: 04/12/2007 072! ~4, AC. i N072 - on 59A-4.109(2), F.A.C Comprehensive Care Plans Resident #5, and #16 have had their care 59A-4.109(2) plans updated to reflect clinical needs, care and services, The facility is responsible to develop a comprehensive care plan for each resident that All residents have the potential to be includes measurable objectives and timetables to affected. meet a resident's medical, nursing, mental and arm 3020-0001 7ORM e899 NONW14 If continuation sheet 8 of 40 gency for Health Care Administration _ ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: B. WING (X2) MULTIPLE CONSTRUCTION A. BUILDING PRINTED: 04/05/2007 FORM APPROVED (X38) DATE SURVEY COMPLETED 33508 Nw. -7 PROVIDER OR SUPPLIER 3MC NURSING CENTER 03/30/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS REFERENCED fo ce APPROPRIATE DATE N.072| Continued Frompage 8- ...... . .-. .. |.nNoz. _/. This plat Of Gorrection constitutes our credible 7 psychosocial needs that are identified in the These or conection vteheaieeeegsomens comprehensive assessment. The care plan must the applicable Federal and state regulations. Nothing describe the services that are to be furnished to Contained herein shall be construed as an admission that attain or maintain the resident's highest the facility violated any federal or state regulation or practicable physical, mental and social failed to follow any applicable standard of care. well-being. The care plan must be completed : within 7 days after completion of the resident assessment. 400.021 (17) "Resident care plan" means a written plan MDS Coordinators and MDS team will than. pe venly bya es rea wewe 4 mn less be trained by an MDS educator on a registered nurse, w “oe participation from other facility staff and the correct RAT process for acter E care resident or his or her designee or legal plans and conducting quarterly reviews representative, which includes a comprehensive _ | based on RAT calendar, |] assessment of the needs of an individual . resident, the type and frequency of services Random audits of at least five residents required to provide the necessary care for the weekly will be conducted on the care resident to attain or maintain the highest plans completed since 3/30/07 and -.--..|-practicable physical, mental, and psychosocial fo _zesults.reported to-the-Director of. well-being, a Tisting of services provided v within or Nursing and/or designee. The director oxo ee ae fom eet eose needs, and an of Nursing and/or designee will report , goes: the audit results monthly to the Quality Improvement Committee for This Rule is not metas evidenced by: recommendations. Audits will continue Based on medical record review and interview, it until compliance sustained. was determined that the facility did not ensure . ] } that Care Plans were appropriately revised to 4[|8 104 accurately reflect the resident's changing status and identified needs, for 2 of 22 sampled residents (#5 and 16). The failure to appropriately revise resident Care Plans has the potential to adversely affect the care and services provided to promote a resident's highest practicable wellbeing. Findings: Form 3020-0001 : : FORM 6899 NONW11 if continuation sheet 9 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for ‘Health Care Administration sTEMENT OF DEFICIENCIES (X38) DATE SURVEY ) PLAN OF CORRECTION COMPLETED (X1) PROVIDERVSUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION IOENTIFICATION NUMBER: A. BUILDING B. WING 33508 03/30/2007 he PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST ‘MC NURSING CENTER LEESBURG, FL 34748 4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) EFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) \.072|-Continued-From-page 9.—----- =... fN.072.. ~| This planrefcorrection-constitutes our-eredible——-- - | =f ' allegation of compliance with licensure requirements. This plan of correction is being submitted pursuant to 1) Record review for resident #5 revealed an the applicable Federal and state regulations. Nothing admission date of 5/11/06 with diagnosis contained herein shail be construed as an admission that including Al dM 1 Stat D. 5 d the facility violated any federal or state regulation or including Altered Mental Stai us, Dementia, an failed to follow any applicable standard of care. Lung Cancer. Review of the Minimum Data Set - Assessment (MDS) revealed the facility had completed the resident's last quarterly assessment on 2/7/07. Review of the plans of care for resident #5, indicated the interdisciplinary team had not documented their quarterly review and/or revision of the following identified care plan goals, for problems identified in the care plan meeting of November 2006: a) Self-care deficit, related to decreased | functional mobility, strength/endurance and pain. b) Toileting schedule to support a reduction of incontinent episodes. c) Potential for falls related to fracture left hip _..,pinning. “d) Risk for skin breakdown due to immobility. “| e) Risk for social isolation due to confusion. f) Extensive assistance from nursing related to dementia. 2) Record review of resident #16 revealed an admission date of 10/10/06 with diagnosis including Shoriness of Breath, Insulin Dependent Diabetes Mellitus, Hypertension, and Chronic Renal Insufficiency. Review of the MDS revealed the facility had completed the resident's last quarterly assessment on 1/19/07. Review of the plan of care for discharge revealed an identified problem of needing to prepare for discharge upon completion of PT (physical therapy), OT “orm 3020-0001 ; FORM 6899 NONW11 If continuation sheet 10 of 40 ) PRINTED: 04/05/2007 FORM APPROVED gency for Health Care Administration ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (X3) DATE SURVEY {X1) PROVIDER/SUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION . 33508 03/30/2007 A * PROVIDER OR SUPPLIER MC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 x4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION x8) 'REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N.072..Continued FROM-Page-1Q ee mm N072. - “This plan of correction‘constitutes‘our éredible “~~~ “fw od " . allegation of compliance with licensure tequirements, (occupational therapy), and ST (speech therapy) - This plan of conection is being submitted pursuant to related to her/his diagnosis and medical the applicable Federal and state regulations. Nothing conditions. The goal with target date of 1/28/07 contained herein shall be construed as an admission that was that resident #16 would be discharged to the facility violated any federal or state regulation or . failed to follow any applicable standard of care. fong term care upon completion of rehab goals. : : Additional record review revealed resident #18 had been discharged from rehab services on 10/26/06 to long term care. Resident #16 has been assessed by the facility on the 1/19/07 MDS as independent in all activities of daily living, and is alert & oriented. However, this goal for discharge had not been revised. These care plan issues for resident #5 and resident #16 were brought to the attention of the care plan coordinators on 3/28/07 at 2:30 PM, who agreed with the findings. The care plan ‘coordinators reported that care plans are not up to date due to a staffing shortage issue. |-Glass-it—— Isolated Correction Date: 04/30/07 \ 082) 59A-4.110(3), F.A.C. Dietary Serv - Supervisor N 082 'S=D! Qualifications No residents were identified. 59A~-4.110(3) : All residents have the potential of bein ected, A Dietary Services Supervisor shall be a person cing aff ho: tos : sys s ane o, - An existing Registered Dietician has (a) ts a qualified dietitian as defined in section assumed the responsibility and title 59A-4.110(2)(a)(b), F.A.C.; or of Dietary Coordinator on a Full (b) Has successfully completed an associate Time basis for the SNF. degree program which meets the education ; standard established by the American Dietetic 4 |iz|oz Association; or : - i “orm 3020-0001 FORM e890 NONW11 f continuation sheet 11 of 40 PRINTED: 04/05/2007 . FORM APPROVED ency for Health Care Administration .TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X83) DATE SURVEY (X1) PROVIDER/SUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 33508 03/30/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 At. _ PROVIDER OR SUPPLIER ‘MC NURSING CENTER «yID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION 5) EFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE | : DEFICIENCY) - N.082/ Continued-From-page 44... —--- -.-2 20... - . N.082.- 1 This Dad Raglan em pe | . is plan of correction constitutes our credible | (c) Has successfully completed a Dietetic qsetion of compliance with licensure requirements. | Assistant correspondence or class room training the cbplicable Federal ona ae veputatn Nothing . + : ula . it program, approved by the American Dietetic contained herein shall be construed as an admis at Association; or the facility violated any federal or state Tegulation or (d) Has successfully completed a course offered failed to follow any applicable standard of care. by an accredited college or university that oe provided 90 or more hours of correspondence, or classroom instruction in food service supervision, and has prior work experience as a Dietary Supervisor in a health care institution with consultation from a qualified dietitian; or (e) Has training and experience in food service supervision and management in the military service equivalent in content to the program in subparagraphs (3)(b), (c) or (d); or (f) Is a certified dietary manager who has successfully completed the Dietary Manager's Course and is certified through the Certifying Board for Dietary | Managers and is maintaining their certificatioi “| with : continuing clock hours at 45 CEU's per three year period. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility does not have a qualified Dietary Services Supervisor for the nursing home. Findings: During observation in the kitchen at 6:45 AM on 3/26/07, the surveyor was informed by the kitchen employee in charge, the Food Service Director would be coming into the facility at approximately Form 3020-0001 " FORM . e898 NONW114 If continuation sheet 12 of 40 \gency for Health Care Administration “AFEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA 1D PLAN OF CORRECTION IDENTIFICATION NUMBER: 33508 \_ F PROVIDER OR SUPPLIER RMC NURSING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES >REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) N.082| Continued From_page_12 PRINTED: 04/05/2007 FORM APPROVED B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 ID PREFIX TAG (X2) MULTIPLE CONSTRUCTION A. BUILDING (X3) DATE SURVEY COMPLETED es 03/30/2007 PROVIDER'S PLAN OF CORRECTION (x8) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N.082 8 AM. Upon entering the kitchen at 11 AM for observation of the lunch tray service, the surveyor met the food service director, who introduced himself as "Food Service Director, Operations Manager" for the nursing home. The surveyor inquired if the FSD was a Certified Dietary Manager (CDM), and he replied he was not a CDM. During an interview on 3/27/07 at 2 PM, the surveyor discussed the state requirements for the position of Dietary Services Supervisor in a nursing home with the Food Service Director. Each requirement was discussed as outlined in the regulations. The Food Service Director stated he did not meet these state qualifications. Review of the Food Service Director's personnel file, revealed his previous recent experience to be executive chef at Leesburg Medical Centar Hospital. There was no documentation to indicate the FSD was a Dietitian, Dietetic Technician, | —— Certified Dietary Manager-or had-military training in food service management. The FSD file contained a position description as Operations Manager for the facility contract food service provider for the nursing home and hospital. On 3/28/07 at 12:15 PM, the Administrator informed the survey team that the Leesburg Hospital Clinical Nutrition Manager was the Food Service Director "system wide". Review of that position description, revealed the Clinical Nutrition Manager reports to the Director of Food & Nutrition Services at Leesburg Medical Center Hospital. Class lll Isolated Correction Date: 4/30/07 ‘orm 3020-0001 FORM 8acg . contained herein shall be construed as an admission that This plan of correction constitutes our credible allegation of compliance with licensure tequirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing the facility violated any federal or state regulation or failed to follow any applicable standard of care, NONW11 If continuation sheet 13 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for'Health Care Administration \TEMENT OF DEFICIENCIES > PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 Vn ~f PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 *MC NURSING CENTER X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) REFIK (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) . N 204; 400.022(1)(I),F.S. Right to Adequate and N 201 This plan of correction constitutes our credible SS=K Appropriate Health Care allegation of compliance with licensure requirements. . This plan of correction is being submitted pursuant to «the applicable Federal and state regulations. Nothin 400.022(1) fa "contained herein shall be construed as an admission that . the facility violated any federal or state Tegulation or (I) The right to receive adequate and appropriate failed to follow any applicable standard of care, health care and protective and support services, ~ if available: planned recreational activities; and therapeutic and rehabilitative services consistent The following identified residents with the resident care plan, with established and #22, #33, #35, #34, and #15, were recognized practice standards within the discharge chart reviews. community, and with rules as adopted by the Residents #28, #30, and #31 have agency. received subsequent accuchecks as ordered, documented on the new diabetic MAR, and existing hypoglycemic protocols followed This Rule. is not met as evidenced by: as per physician orders, Based observation, record review, and.staff interviews the facility failed for 11 of 38 residents Review of ordered medications for (#22,28,30, 32,35,34,33,14,15,7, and 31) to Resident #7, #14, #32, and #15 ensure the resident's right to receive adequate have determined that all and appropriate health care by failing to provide medications are available for _...| care_and services in accordance withthe. a administration from the assigned | resident's plan of care. Failure to provide medication cart. . physician prescribed care and services created a serious and immediate threat to the health and All residents have the potential to be wellbeing of the residents. affected, Findings: Initiated training 3/30/07 for all 1. Review of the medical record for Resident #22 nursing staff to include PRN revealed the resident was admitted on staff on existing . . 01/12/2007 with a diagnosis of Diabetes Mellitus. medication administration, existing On 1/12/2007 bloods sugar levels (BS) were : hypoglycemic protocol, customer ordered to be performed before meals and at service, behavior standards, bedtime. Included in the admission orders dated physician notification, 1/12/07 was a protocol for the nursing staff to follow in the event the resident ' s blood sugar was low enough to warrant intervention. The Emergency Drug Kit use and Medication errors by DON, order dated 01/12/07 was listed as #3 of page , euanmacy Consultant and nurse two on the Physician Order Sheet (POS) and Onsultant. ‘Training completed on Form 3020-0001 FORM = oo "Tea NONWET TOT “"~ "if 6Gntinuatio Shéet 14 OF 40 } PRINTED: 04/05/2007 FORM APPROVED ency for:Health Care Administration ATEMENT OF DEFICIENCIES 2 PLAN OF CORRECTION (41) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: {X3) DATE SURVEY (X2) MULTIPLE CONSTRUCTION COMPLETED 33508 03/30/2007 ‘ PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 MIC NURSING CENTER X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N-204-] -GontinuedFrom-page-44——-__ | -.N-204- See — Spo] This plan of correction constitutes our credible appeared as: allegation of compliance with licensure tequirements, This plan of correction is being submitted pursuant to Dextrose 50 % water Abboject the applicable Federal and state regulations. Nothing _ wo contained herein shall be construed as an admission that BS(80=1/2 glass apple juice ) the facility violated any federal or state regulation or BS (70=1 glass apple juice) failed to follow any applicable standard of care, BS (60 inject % amp) . . BS (50 inject 1 : (50 inject 4 amp) 4/11/07. New staff or staff retuming Review of the medical record for resident #22 from LOA will receive training revealed the following BS for the resident on ongoing. The nursing 01/18-17/07 with intervention performed by the secretary will provide all agency nurse, nurses handouts in regards 1/16/07 to mandatory training prior to 3:00 PM-11:00 PM Nurse 1635=65, Glass of Apple juice 1740=97, No interventions working with residents. As of 3/30/07, the Risk Manager will | 2026=66, Glass of Apple juice review the medical record of any i| 14:00 PM -7:00 AM Nurse unexpected death and teport findings 2330=43, Two glasses of apple juices to the Risk Committee as of 3/30/07 04/17/07 using existing Incident Reporting 0008=31, Two apple juices and two orange juices System. DON or NHA to initiate ——|.0021=42, Health Shake and 3instantoral | -Phone call to Risk Manager on any || cose. adverse incident. The Risk 0058=30, No interventions documented Committee will then make further 0132=33, Attempted to start IV - Tecommendations as d d 0143=38, Resident cardiac arrest, expired. ns 8s deeme necessary. To obtain medications in a timely Medical record review did not reveal that the physician was notified of the low BS. Interview manner, all new and refill with the 11:00 PM to 7:00 AM nurse on 3/29/2007 medications will be faxed by the at 9:15 AM revealed "Did not do the protocol nurse to the pharmacy followed bya because the health shakes usually work". When phone call. The courier will be asked why the physician was not called the nurse contacted to pick up and deliver the Stated that"! never call the physicians but | would medications ordered as of4/2/07, All just sent the residents to the Emergency Room if medication will be supplied in a needed." timely manner such that no resident Interview with the resident's physician by will be subjected to discomfort or telephone on 03/29/2007 at 9:00 AM revealed his/her nealth ey that he would have expected a telephone call compromised. If pharmacy is unable orm 3020-0001 =ORM e899 NONW11 lf continuation sheet 15 of 40 PRINTED: 04/05/2007 FORM APPROVED \gency for Health Care Administration SABEMENT OF DEFICIENCIES ND PLAN OF CORRECTION {X3) DATE SURVEY COMPLETED (X1) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: 33508 03/30/2007 By PROVIDER OR SUPPLIER ‘RMC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES io PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) -N-2044 -Continued-From-page 45- tae rN 204 _ — — | This plan of correction constitutes our credible from the 11:00 PM to 7:00 AM nurse for this allegation of compliance with licensure requirements. resident concerning the low BS but I did not get This plan of correction is being submitted Pursuant to one . the applicable Federal and state tegulations. Nothing contained herein shall be construed as an admission that . . . | the facility violated any federal or state regulation or Interview with the Director of Nursing (DON) on | failed to follow any applicable standard of care. 03/28/2007 at 10:00 AM revealed that the medical record (unexpected death) was not reviewed as-part of the quality improvement to meet the above standard, the SNF program. Administrator will then be notified, The SNF Administrator will then 2. Observation of Medication pass for resident notify pharmacy management #15 on 03/26/07 at 8:35 AM, revealed the personnel to insure compliance, medication, Zyvox (an antibiotic to treat the Inventory of the Emergency Drug resident pneumonia) was not given, the medication nurse for this resident, stated the by the Medical Director for medication was not available from pharmacy yet ; : completeness on 4/9/07. The EDK . and the resident has not received any doses yet Kits was changed on 4/10/07 to Kits (maintained on site) reviewed Review of the Physicians orders reveals the include medications that likely will Zyvox for resident #15 was ordered 03/23/07 at meet the needs of first dosing of | 10 PM. Interview 03/26/2007 at 8:35 AM with antibiotics, pain medications and --— +Medication nurse reveals she calledthe | —-_---_|_ Widely prescribed emergency __ ——— pharmaey-and-was toid-they-would-have-the + medications, and placed in service, Zyvox for the 8 PM dose 03/26/07. A complete audit of all medication . carts was done t 3. Observation of Medication pass for resident of Boe ee that every #14 on 03/26 07 at 8:20 AM revealed that the medication on the MAR was present -| medication nurse for this resident flipped the in © Medication cart and/or Medication Administration Record (MAR) over _ obtained on 3/30/07. Daily tandom and wrote "Med out of stock ,has reorder". The audits of medication availability in medication nurse for resident #14 was assigned cart (at a minimum of 5 questioned by this surveyor at this time. The residents per wing) will continue medication nurse stated that she did not give the until compliance is sustained by unit Lactinex dose as they do not have the pill form as manager or designee. Results will be ordered and that the resident will not take powdered form. Review of the MAR indicates the resident has not had Lactinex for 15 days. teviewed in daily Morning standup meeting, weekly Standard of Care Record review revealed that on 3/21/06 12:00 nee and the Monthly Quality noon the nurse wrote on back of MAR "Has been mprovement Committee with reordered many times." . appropriate actions taken, Form 3020-0001 FORM e508 NONW11 'f continuation sheet 16 of 40 } PRINTED: 04/05/2007 FORM APPROVED \gency for Health Care Administration “ATEMENT OF DEFICIENCIES 1D PLAN OF CORRECTION (X3) DATE SURVEY X1) PROVIDER/SUPPLIER/CLIA &1) E COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 33508 03/30/2007 . F PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 RMC NURSING CENTER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) (X4) OREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) . -N201, Continued-From-page-16————__________|_m204 : “= —~ ede me This plan of correction constitutes our credible allegation of compliance with censure requirements. 4. Record review for resident #31 revealed that "| This plan of correction is being submitted pursuant to ~ " the applicable Federal and state tegulations, Nothing the resident # 31 has a hypoglycemic protocol contained herein shall be construed as an admission that ordered on 03/13 /07, it reads as follows: the facility violated.any federal or state regulation or failed to follow any applicable standard of care. Dextrose 50 % water Abboject : ‘BS(80=1/2 glass apple juice ) a sas BS (70=1 glass apple juice) A new diabetic Medication BS (60 inject % amp) -}| Administration Record was BS (50 inject 1 amp) implemented 3/30/07 to include the accucheck result, sliding scale dose Review of resident #31's blood sugars for the as indicated, site of administration as month of March revealed that on 03/15/07 indicated and hypoglycemic protocol resident #31 had a Blood Sugar (BS) of 71, on to be followed. All routine 03/17/07 a BS of 52, on 03/19/07 a BS of 79, on accuchecks will be audited by the 03/25/07 a BS of 68 and on 03/28/07 a BS of 67, Further review of the MAR in the Hypoglycemia protocol section revealed no entries to indicate the protocol had been followed. Nurse Consultant and/or designee for correct implementation of sliding scale and hypoglycemic protocol. Results will be reviewed in daily 5. Closed record review for resident #35 revealed morning standup meeting, weekly -the resident was admitted 02/11/07 at 6:30 PM.._| ____| Standard of Care Meeting, and _ Vview-of the-MAR -indicated-an-orderfor_ ———_--»—- —Monthiy Quality Improvement Rocephin (an antibiotic) not available 02/12/07 Committee with appropriate actions and 2/13/07 , Paxil (used to treat depression) not taken. Inservicing of all LRMC available on 02/12/07, Colace (stool softener) not A available 02/13/07. No médications were on the ane aon wee cone MAR were signed off as given until 02/13/07. : Tei customer service, grievances, 6. Closed record review for resident #34 revealed abuse/neglect, and Proper answering the resident was admitted to the facility on of resident call lights. This inservice 02/11/07 at 5:00 PM. Review of the MAR was conducted by the Nurse revealed Coreg (for blood pressure) and-Zocor Consultant and/or designee. Daily (for cholesterol) not available 2/11/07, Amaryl (for random observation audits (five Diabetes) not available 02/12/07, Evista (to residents) will be conducted on each prevent Osteoporosis), Avandia (for Diabetes), unit by the Director of Nursing Zoloit (for depression), also not available. Colace (stool softener) not available on 02/13/07. Further review of the MAR reveals that resident #34 did not receive any medications until their 8:00 PM Form 3020-0001 FORM . bass NONW11 if continuation sheet 17 of 40 ) and/or designee, to monitor call-light response time and resident satisfaction until compliance gency for Health Care Administration ‘ATEMENT OF DEFICIENCIES 1D PLAN OF CORRECTION RMC NURSING CENTER PRINTED: 04/05/2007 FORM APPROVED (X1) PROVIDER/SUPPLIER/CLIA (IDENTIFICATION NUMBER: 33508 PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION ({X3) DATE SURVEY COMPLETED STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 03/30/2007 x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION to SREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) -N-20+-Gontinued From-page-17—— +-N-204 - _— -| dose on 02/12/07. 7. Closed record review for resident #33 revealed the resident was admitted to the facility 02/03/07 at 7:00 PM. Review of the MAR revealed a Calcium (a supplement) was not available 02/13/07, Seroquel (for psychotic disorders) was not available 2/13/07, Namenda (Alzheimers treatment) was not available on 02/13/07. 8. Record review revealed Resident #28 was admitted on 7/25/05 with diagnosis including Diabetes Mellitus, Schizophrenia, Hypertension, and Psychotic Disorder. Review of the March 2007 Medication Administration Record (MAR) revealed blood sugar (accucheck) before meals and at bedtime. The resident had physician orders for Sliding Scale Insulin coverage with Novolin R Insulin as follows: Blood Sugar 200-249 give 2 units Blood Sugar 250-299 give 4 units __ ———+ Blood-Sugar 300-349 give 6-units taken, This plan of correction constitutes our credible | allegation of compliance with licensure requirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing contained herein shall be construed as an adrnission that the facility violated any federal or state reguiation or failed to follow any applicable standard of care, sustained. Results will be reviewed in daily morning standup meeting, - Standards of Care meeting, and Monthly Quality Improvement Committee with appropriate actions Nurses/CNAs will be counseled as indicated based on non compliance with expected standards. Pertinent issues will also be forwarded to the Risk Committee, HiloF Review of the March 2007 MAR revealed the following blood sugars recorded at 200 and above. There was no documentation on the MAR that insulin coverage was given at these times: 31° @ GAMof209 3/4 @ 11:30 AM of 207 310 @ 11:30 AM of 205 3/14. @ 11:30 AM of 225 3/18 @ 11:30 AM of 234 3/20 @ 11:30 AMof219 4:30 PM of 243 8:00 PM of 245 3/24 @ 11:30 AM of 260 3/25 = @ 11:30 AM of 230 3/26 = @ 11:30 AM of 210 Form 3020-0001 FORM 4 } NONW11 If continuation sheet 18 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Heaith Care Administration \TEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA > PLAN OF CORRECTION IDENTIFICATION NUMBER: {X3) DATE SURVEY COMPLETED (X2) MULTIPLE CONSTRUCTION A. BUILDING ee B. WING : 33508 03/30/2007 : ) PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 {MC NURSING CENTER <4) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) \-204,)-Continuied-From-page-18— ———|-N-204 - - | 3/27 @ 8 PM of 227 This plan of correction constitutes our credible allegation of compliance with licensure Tequirements. . . This plan of correction is being submitted pursuant to j i ( i the applicable Federal and state regulations, Nothing In an interview with the Unit Manager on 3/29/07 contained herein shall be construed as an admission that at 12:10 PM, it was stated there was no proof the facility violated any federal or state regulation or whether nurses gave the insulin or not on those _| failed to follow any applicable standard of care. dates. There was no other place where the . ~ medication administration was typically charted. 9. Record review revealed Resident #30 was readmitted on 3/1/07 with diagnosis including Insulin Dependent Diabetes Mellitus (IDDM), CVA, Dysphagia and Decubitus. Review of the March 2007 MAR revealed blood sugar (accucheck) before meals and at bedtime. The resident had physician orders for Sliding Scale | Insulin coverage with Novolin R Insulin as follows: Blood Sugar 201-250 give 4 units | Blood Sugar 251-300 give.6 units _ Blood.Sugar 151-200 give 2 units | | Review of the March 2007 MAR revealed the | following blood sugars recorded at 151 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/3 @ 11:30 AM of 151 3/4 @ 4:30 PM of 172 3/7 @8 PM of 151 3/8 @ 4:30 PM of 210 3/9 @ 4:30 PM of 232 3/13 @ 8 PM of 192 3/16 @ 8 PM of 173 3/19 @ 4:30 PM of 174 3/20 @ 4:30 PM of 218 3/22 @ 4:30 PM of 232 3/25 @ 11:30 AM of 168 3/26 @ 11:30 AM of 161 orm 3020-0001 =ORM 8899 NONW11 If continuation sheet 19 of 40 PRINTED: 04/05/2007 FORM APPROVED gency for,Health Care Administration ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 | ¥ PROVIDER OR SUPPLIER MC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 , X4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE _ COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) : N-204-Gontinued-From-page49———_________._.___]_noo4_. — This plan of correction constitutes our credible allegation of compliance with licensure requirements, Interview with the Unit Manager on 3/30/07 This plan of correction is being submitted Pursuant to revealed no further documentation of insulin one spplicable jaaeral and State regulations. Nothing medication administration could be provided. jolted ape geostued as an admission that - the facility violated any federal or state tegulation or failed to follow any applicable standard of care, 10. Record review revealed Resident #32 was admitted 2/4/07 at 7:30 PM, with physician medication orders for Preservision Softgels, take 1 capsule by mouth 2 times daily. Review of the MAR revealed the medication not given for either. dose on 2/5/07, and on order from the pharmacy. Physician orders 2/5/07 were documented for Resident #32 for Albuterol .83 mg/ml solution and ipratropium BR .02% solution, use 1 unit of each in updraft every 8 hours. Review of the February 2007 MAR revealed the medications were not signed off as administered, on the following dates forthe 11 PM dose: 2/5, 2/9, 2/13, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/22, 2/23 and 2/24/07. --_| There was no explanation documented by -—Thuek he MAR as-fo-why th overs jee meee fee ee ce ee ee et et eee eee ef eee | = omitted.. In interview with the Director of Nurses (DON) at 1:40 PM on 3/30/07, it was stated that it looked like Albuterol was omitted on those dates. No further documentation was provided. 11. Record review revealed Resident #7 was admitted on 3/13/07 with diagnosis of Esophageal Cancer, Status Post Radiation Treatment & Chemotherapy. Review of the MAR revealed physician orders on 3/13/07 for Morphine Sulfate 15 mg Tab SA, substitute for MS Contin 15 mg SA, take 3 tablets every 8 hours. On 3/18/07 the resident's 10 PM dose was omitted. The reason documented by nursing on the MAR was the "VMS Contin was on order.” On 3/19/07 the resident's ‘orm 3020-0001 FORM 6899 NONW14 If continuation sheet 20 of 40 ency for, Health Care Administration \TEMENT 2 PLAN O} \ X4) ID REFIX TAG N2014 Continued From_page 20 ¥ PROVIDER OR SUPPLIER *MC NURSING CENTER OF DEFICIENCIES F CORRECTION {X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 33508 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING PRINTED: 04/05/2007 STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 {X3) DATE SURVEY COMPLETED 03/30/2007 FORM APPROVED PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETE DATE 6 AM and 2 PM doses were omitted. The reason documented. by nursing on the MAR for omission of the 2 PM dose, was the medication was "not available from the pharmacy." There was no explanation documented by nursing for the omission of the 6 AM dose on 3/19/07. Review of the MAR documented physician orders dated 3/13/07, for Nystatin 100,000 U/ml suspension, swish & swallow, 1 teaspoon 4 times daily. On 3/25/07 the 12 noon, 4 PM, and 8 PM doses were omitted. The reason documented on the MAR for the omission at 12 noon and 4 PM was the med "not available from pharmacy." There was no explanation documented by nursing for the omission of the 8 PM dose. Interview with the DON on 3/28/07 at 10:30 AM, revealed no further documentation could be provided for the omission of resident #7's medications. allegation of compliance with licensure tequirements. This pian of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing - contained herein shall be construed as an admission that the facility violated any federal or state regulation or failed to follow any applicable standard of care. 1216 ‘S=K Class{— Pattern Correction date:04/12/2007 400.102(1)(a) Health and Safety of Resident 400,102(1)(a) (1) Any of the following conditions shall be grounds for action by the agency against a licensee; (2) An intentional or negligent act materially affecting the health or safety of residents of the facility. The following identified residents #22, #33, #35, #34, and #15, were discharge chart reviews. Residents #28, #30, and #31 have received subsequent accuchecks as ordered, documented on the new diabetic MAR, and existing hypoglycemic protocols followed as per physician orders. Review of ordered medications for Resident #7, #14, #32, and #15 have determined that all medications are available for NONW11 lf continuation sheet 21 of 40 ency for Health Care Administration TEMENT OF DEFICIENCIES PLAN OF CORRECTION (X1) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER: 33508 7 }PROVIDER OR SUPPLIER MC NURSING CENTER 4) 1D SUMMARY STATEMENT OF DEFICIENCIES REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL “AG REGULATORY OR LSC IDENTIFYING INFORMATION) STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 { PREFIX TAG N246 (X2) MULTIPLE CONSTRUCTION PRINTED: 04/05/2007 FORM APPROVED {X3} DATE SURVEY COMPLETED 03/30/2007 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (x5) COMPLETE DATE ee nin Bron poge 2 T his Rule is not met as evidenced by: Based record review, staff interviews, resident group interviews, and facility document review the facility failed to implement policies and procedures to prevent neglect by failing to ensure care and services to provide physician ordered medications and prescribed care for diabetics for 16 of 44 residents reviewed: (Resident # 22,28,30,32,35,34,33,14,15,31,39,40,41, 42,43,and 44) This failure created a serious and immediate threat to the health, safety and wellbeing of the resident within the facility. Findings: 1. Review of the medical record for Resident #22 revealed the resident was admitted on ,| 01/12/2007 with a diagnosis of Diabetes Mellitus. | On 1/12/2007 bloods sugar levels (BS) were ordered to be performed before meais and at bedtime. Included in the admission orders dated | 1/42/07 was a protocol for the nursing staffto | This plan of correction Ce constitutes our credible allegation of compliance with licensure requirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing contained herein shall be construed as an admission that the facility violated any federal or state regulation or failed to follow any applicable standard of care. administration from the assigned medication cart. Random interviews with resident #9, #23, #39, #42, #43, and #44 have revealed improvement in satisfaction with call lights and response. All residents have the potential to be affected. Initiated training 3/30/07 for all nursing staff to include PRN staff on existing medication administration, existing V ident+s blood-suga was low enough to warrant intervention. The order dated 01/12/07 was listed as #3 of page two on the Physician Order Sheet (POS) and appeared as: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (50 inject 1 amp) Review of the medical record for resident #22 revealed the following BS for the resident on 01/16-17/07 with intervention performed by the nurse. 1/16/07 3:00 PM-11:00 PM Nurse “orm 3020-0001 FORM service, behavior standards, physician notification, Emergency Drug Kit use and Medication errors by DON, Pharmacy Consultant and Nurse Consultant. Training completed on 4/11/07. New staff or staff returning from LOA wiill receive training ongoing. The nursing secretary will provide all agency nurses handouts in regards to mandatory training prior to working with residents. As of 3/30/07, the Risk Manager will review the medical record of any NONW11 If continuation sheet 22 of 40 gency for Health Care Administration ATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA 'D PLAN OF CORRECTION IDENTIFICATION NUMBER: 33508 4. PROVIDER OR SUPPLIER RMC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 {X2) MULTIPLE CONSTRUCTION PRINTED: 04/05/20° FORM APPROV. {X3) DATE SURVEY COMPLETED 03/30/2007 xa) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x8) 7REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) . N216,-Continued From-page.22_ — ——-N216____This pian ofcomectionconstitutes ourcredible | 1635=65, Glass of Apple juice 1740=97, No interventions 2026=66, Glass of Apple juice 11:00 PM -7:00 AM Nurse 2330=43, Two glasses of apple juices 01/17/07 0008=31, Two apple juices and two orange juices 0021=42, Health Shake and 3 instant oral glucose | 0058=30, No interventions documented 0132=33, Attempted to start IV . 0143=38, Resident cardiac arrest, expired. Medical record review did not reveal that the physician was notified of the low BS. Interview with the 11:00 PM to 7:00 AM nurse on 3/29/2007 at 9:15 AM revealed "Did not do the protocol because the health shakes usually work". When asked why the physician was not called the nurse stated that "| never call the physicians but | would just sent the residents to the Emergency Room if _[ needed." : allegation of compliance with licensure requirements. , This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing . contained herein shall be construed as an admission that the facility violated any federal or'state regulation or - failed to follow any applicable standard of care. unexpected death and report findings to the Risk Committee as of 3/30/07 using existing Incident Reporting System. DON or NHA to initiate phone call to Risk Manager on any adverse incident. The Risk Committee will then make further recommendations as deemed” necessary, To obtain medications in a timely manner, all new and refill medications will be faxed by the nurse to the pharmacy followed by a phone call. The courier will be 5 Interview with the resident's physician by telephone on 03/29/2007 at 9:00 AM revealed that he would have expected a telephone call from the 11:00 PM to 7:00 AM nurse for this resident concerning the low BS but] did not get one. Interview with the Director of Nursing (DON) on 03/29/2007 at 10:00 AM revealed that the medical record (unexpected death) was not reviewed as part of the quality improvement program. 2. Observation of Medication pass of resident #15 on 03/26/07 at 8:35 AM, revealed the medication, Zyvox (an antibiotic to treat the resident Pneumonia) was not given, the medication nurse “orm 3020-0001 FORM ) 6e99 medication will be supplied in a timely manner such that no resident will be subjected to discomfort or his/her health and safety compromised. If pharmacy is unable to meet the above standard, the SNF Administrator will then be notified, The SNF Administrator will then notify pharmacy management personnel to insure compliance, Inventory of the Emergency Drug Kits (maintained on site) reviewed by the Medical Director for completeness on 4/9/07. The EDK. Kits was changed on 4/10/07 to” NONW114 include medications that likely will if continuation sheet 23 of 40 PRINTED: 04/05/2¢;_* FORM APPROVE: gency for Health Care Administration . ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING SS 33508 03/30/2007 i E PROVIDER OR SUPPLIER R3MC NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N-216/-Continued-Frompage-23 on ++ -N.216___thisplanofcoection-constitutesourcredible___| | _ A . tgs allegation of compliance with licensure requirements, for this resident, stated the medication was not This plan of correction is being submitted pursuant to available from pharmacy yet and the resident has the applicable Federal and state regulations, Nothing not received any doses yet contained Tierein shall be construed as an admission that the facility violated any federal or state regulation or A we failed to follow any applicable standard of care. Review of the Physicians orders reveals the ae ° ow Y app Zyvox for resident #15 was ordered 03/23/07 at 10 PM. Interview 03/26/2007 at 8:35 AM with meet the needs of first dosing of Medication nurse reveals she called the anti loties, pal medications and pharmacy and was told they would have the widely prescribed emergency Zyvox for the 8 PM dose 03/26/07. medications, and placed in service. A complete audit of all medication 3. Observation of Medication pass for resident of carts was done to ensure that every #14 on 03/26 07 at 8:20 AM revealed that the medication on the MAR was present medication nurse for this resident flipped the in the medication cart and/or Medication Administration Record (MAR) over obtained on 3/30/07. Daily random and wrote "Med out of stock ,has reorder’. The medication nurse for resident #14 was questioned by this surveyor at this time. The * audits of medication availability in assigned cart (at a minimum of 5 medication nurse stated that she did not give the residents per Wing) will continue ; Lactinex dose as they do not have the pill form as until compliance is sustained by unit ordered and that the resident will not take manager or designee. Results will be powdered form. Review of the MAR indicates the |__| reviewed in daily morning standup | -—— resident has not had _Lactinex for 45 days. meeting, weekly Standard of Care a Record review revealed that on 3/21/06 12:00 : meeting, and the Monthly Quality noon the nurse wrote on back of MAR "Has been Improvement Committee with reordered many times. appropriate actions taken, 4. Record review for resident #31 revealed that A new diabetic Medication the resident had a hypoglycemic protocol ordered Administration Record was on 03/13 /07, it reads as follows: implemented 3/30/07 to include the accucheck result, sliding scale dose bb as indicated, site of administration as BS(80=1/2 glass apple juice ) indicated and hypoglycemic protocol Bs ot glass apple juice) to be followed. All routine BS 5 9 inject tammy accuchecks will be audited by the Nurse Consultant and/or designee for Dextrose 50 % water Abboject Review of resident #31 's blood sugars for the correct implementation of sliding month of March revealed that on 03/15/07 seale and hypoglycemic protocol. resident #31 had a Blood Sugar (BS) of 71, on Results will be reviewed in daily “orm 3020-0007 FORM 609 NONW11 lf continuation sheet 24 of 40 gence ATEMENT OF DEFICIENCIES D PLAN i _JF PROVIDER OR SUPPLIER RMC N -N-216_Continued-From-page-24 for Health Care Administration (X41) PROVIDER/SUPPLIER/CLIA OF CORRECTION IDENTIFICATION NUMBER: 33508 URSING CENTER SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X2) MULTIPLE CONSTRUCTION PRINTED: 04/05/2007 FORM APPROVED STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 03/17/07 a BS of 52, on 03/19/07 a BS of 79, on 03/25/07 a BS of 68 and on 03/28/07 a BS of 67. Further review of the MAR in the Hypoglycemia protocol section revealed no entries to indicate the protocol had been followed. 5. Closed record review for resident #35 revealed the resident was admitted 02/11/07 at 6:30 PM. Review of the MAR indicated an order for Rocephin (an antibiotic) not available 02/12/07 and 2/13/07 , Paxil (used to treat depression) not available on 02/12/07, Colace (stool softener) not available 02/13/07. No medications were on the MAR were signed off as given until 02/13/07. 6. Closed record review for resident #34 revealed the resident was admitted to the facility on 02/11/07 at 5:00 PM. Review of the MAR Form } . | prevent Osteoporosis), Avandia (for Diabetes), ——+Zeleth = FORM This plan of correction constitutes our credible allegation of compliance with licensure requirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing contained herein shall be construed as an admission that the facility violated any federal or state regulation or failed to follow any applicable standard of care, moming standup meeting, weekly Standard of Care Meeting, and Monthly Quality Improvement Committee with appropriate actions taken. Inservicing of all LRMC Nursing Center staff were done 3/31/07 — 4/11/07 in regards to customer service, grievances, abuse/neglect, and proper answering of resident call lights. This inservice was conducted by the Nurse | Consultant and/or designee. Daily random observation audits (five _| residents) will be conducted on each, . (X3) DATE SURVEY COMPLETED 03/30/2007 (X86) COMPLETE DATE (stool softener) not available on 02/13/07.-Further review of the MAR reveals that resident #34 did not receive any medications until their 8:00 PM dose on 02/12/07. 7. Closed record review for resident #33 revealed the resident was admitted to the facility 02/03/07 at 7:00 PM. Review of the MAR revealed a Calcium (a supplement) was not available 02/43/07, Seroquel (for psychotic disorders) was not available 2/13/07, Namenda (Alzheimers treatment) was not available on 02/13/07. 8. Record review revealed Resident #28 was admitted on 7/25/05 with diagnosis including Diabetes Mellitus, Schizophrenia, Hypertension, and Psychotic Disorder. Review of the March 3020-0001 unit by the Director of Nursing and/or designee, to monitor call-light response time and resident satisfaction until compliance sustained. Results will be reviewed in daily morning standup meeting, Standards of Care meeting, and Monthly Quality Improvement - Committee with appropriate actions taken. Nurses/CNAs will be counseled as indicated based on non compliance with expected standards. Pertinent issues will also be forwarded to the NONW11 Risk Committee, if continuation sheet 25 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for-Health Care Administration TEMENT OF DEFICIENCIES ' PLAN OF CORRECTION (X14) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X3) DATE SURVEY COMPLETED {X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 33508 03/30/2007 1 IPROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 MC NURSING CENTER 4) 1D SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE “AG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) +-246-Centinued-From page-25 - | N246. Pi Biso-of correction constitutes our eredisle ———}—- ~~ —.- co. , . allegation of compliance with licensure i . 2007 Medication Administration Record (MAR) This plan of correction is being submitted pursuant to revealed blood sugar (accucheck) before meals the applicable Federal and state regulations, Nothing and at bedtime. The resident had physician tee’ herein shall be construed as an admission that orders for Sliding Scale Insulin coverage with Ged ne iolsted any federal or state regulation or E + failed to foll i Novolin R insulin as follows: ailed to follow any applicable standard of care, Blood Sugar 200-249 give 2 units Blood Sugar 250-299 give 4 units Blood Sugar 300-349 give 6 units Review of the March 2007 MAR revealed the following blood sugars recorded at 200 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/1 @6AM of 209 3/4 @ 11:30 AM of 207 3/10 @ 11:30 AM of 205 3/14 @ 11:30 AM of 225 3/18 =@11:30 AM of 234 3/20 @11:30 AM of 219 4:30 PM of 213 8:00-PM-of 245 3/24 =@ 11:30 AM of 260 3/25 = =@ 11:30 AM of 230 3/26 = @ 11:30 AM of 210 3/27, @ 8 PMof 227 In an interview with the Unit Manager on 3/29/07 at 12:10 PM, it was stated there was no proof whether nurses gave the insulin or not on those dates. The Unit Manager confirmed that there was no other place where the medication administration was typicaily charted. 9, Record review revealed Resident #30 was readmitted on 3/1/07 with diagnosis including Insulin Dependent Diabetes Mellitus (IDDM), arm 3020-0007 7O0RM ease NONW11 lf continuation sheet 26 of 40 PRINTED: 04/05/2007 FORM APPROVED \TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X3) DATE SURVEY (X1) PROVIDER/SUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 33508 03/30/2007 PROVIDER OR SUPPLIER ‘MC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 <4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) EFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY): + Gontinued-From-page-26- This plan of correction constitutes our credible allegation of compliance with licensure requirements. CVA, Dysphagia and Decubitus.. Review of the March 2007 MAR revealed blood sugar "This plan of correction is being submitted pursuant to (accucheck) before meals and at bedtime. The the applicable Federal and state regulations. Nothing resident had physician orders for Sliding Scale Contained herein shall be construed as an’admission that the facility violated any federal or state regulation or Insulin coverage with Novolin R Insulin as follows: failed to follow any applicable standard of care. Blood Sugar 151-200 give 2 units Blood Sugar 201-250 give 4 units Blood Sugar 251-300 give 6 units Review of the March 2007 MAR revealed the following blood sugars recorded at 151 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/3 @ 11:30 AM of 151 3/4 @ 4:30 PM of 172 3/7 @8 PM of 151 3/8 @ 4:30 PM of 210 3/9 @ 4:30 PM of 232 3/13 @ 8 PM of 192 __1 3/16 @ 8 PM of 173 _. ee — | ; et . T3436 Pit of 174 3/20 @ 4:30 PM of 218 3/22 @ 4:30 PM of 232 3/25 @ 11:30 AM of 168 3/26 @ 11:30 AM of 161 Interview with the Unit Manager on 3/30/07 at 1:40 PM reveaied no further documentation of insulin medication administration could be provided. 10. Record review revealed Resident #32 was admitted 2/4/07 at 7:30 PM, with physician medication orders for Preservision Softgels, take 1 capsule by mouth 2 times daily. Review of the MAR revealed the medication not given for either dose on 2/5/07, and on order from the pharmacy. Form 3020-0001 " FORM epeo NONW11 lf continuation sheet 27 of 40 } PRINTED: 04/05/2007 FORM APPROVED ency for.Health Care Administration \TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X3) DATE SURVEY (X1) PROVIDER/SUPPLIERICLIA COMPLETED IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 *\ }PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 {MC NURSING CENTER <4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG” REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) \.2161 Continued From-page.27. - -—|-N.246_. This plan of correction constitutes our credible allegation of compliance with licensure tequirements. Physician orders 2/5/07 were documented for i orcas een being veo Nothing Resident #32 for Albuterol .83 mg/ml solution and contained herein shall be construed as an admission that Ipratropium BR .02% solution, use 1 unit of each the facility violated any federal or state regulation or in updraft every 8 hours. Review of the February failed to follow any applicable standard of care, 2007 MAR revealed the medications were not signed off as administered, on the following dates for the 11 PM dose: 2/5, 2/9, 2/13, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/22, 2/23 and 2/24/07. There was no explanation documented by nursing on the MAR as to why the doses were omitted. In interview with the Director of Nurses (DON) at 1:40 PM on 3/30/07, it was stated that it looked like Albuterol was omitted on those dates. No further documentation was provided. 11. Record review revealed Resident #7 was admitted on 3/13/07 with diagnosis of Esophageal Cancer, Status Post Radiation Treatment & Chemotherapy. Review of the MAR revealed ——+-Physician-orders on 3/13/07 for Morphine Sulfate 15 mg Tab SA, substitute for MS Contin 15 mg SA, take 3 tablets every 8 hours. On 3/18/07 the resident's 10 PM dose was omitted. The reason documented by nursing on the MAR was the "MS Contin was on order." On 3/19/07 the resident's 6 AM and 2 PM doses were omitted. The reason documented by nursing on the MAR for omission of the 2 PM dose, was the medication was "not available from the pharmacy." There was no explanation documented by nursing for the omission of the 6 AM dose on 3/19/07. Continued review of the MAR documented physician orders dated 3/13/07, for Nystatin 100,000 U/ml suspension, swish & swallow, 1 teaspoon 4 times daily. On 3/25/07 the 12 noon, 4 PM, and 8 PM doses were omitted. The “orm 3020-0001 FORM 699 NONW11 If continuation sheet 28 of 40 ) PRINTED: 04/05/2007 FORM APPROVED gency for Health Care Administration ATEMENT OF DEFICIENCIES (X3) DATE SURVEY D PLAN OF CORRECTION X1) PROVIDER/SUPPLIER/C! 1) DENS LIA COMPLETED IDENTIFICATION NUMBER: {X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 33508 03/30/2007 fl } PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 MC NURSING CENTER XA) 1D SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDER'S PLAN OF CORRECTION %) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N.216}-Continued-Erom-_page 28. ; N216- : . - - . This plan of Correction constitutes our credible reason documented on the MAR for the omission meter of compliance with licensure requirements, at 12 noon and 4 PM was the med "not available the applicable Feder cag shite eae eNO : wations, from pharmacy." There was no explanation ; contained herein shail be construed as an admission that documented by nursing for the omission of the 8 the facitity violated any federal or state regulation or PM dose. failed to follow any applicable standard of care. Interview with the DON on 3/28/07 at 10:30 AM, revealed no further documentation could be provided for the omission of resident #7's medications. 12. On 03/27/07, during the 10:15 AM group interview, 6 of the 10 (resident #9, 23, 39, 42, 43, and 44) residents in attendance reported that each of them has experienced an incontinent episode within the last 3 months. The residents reported that this occurred because staff who answered their call bells did not provide care instead but turned off the light, telling the resident's they were not their assigned CNA and the resident would have to wait for care to be _| provided when their assigned CNA was available. —_—+-the-residents revealed-they-have-allwaited-over —= — ~ 45 minutes for their assigned CNA to provide : care because either they were on a break or they were not notified by the staff member who initially responded to the bell/light. On 03/27/07, during a 4:28 PM interview with staff member CNA #1 regarding call bells/lights, CNA #1 stated that although CNAs are assigned room numbers to cover on their shift, everyone is supposed to assist if a CNA goes on a break or if a resident call bell/ight goes on when you are walking down the hall. CNA #1 reported that you never know why that light is on so you should answer it. CNA #1 reported that her assigned resident's have brought to her attention that they have been made to wait for care to be provided while she has been on a break or busy attending Form 3020-0001 FORM 6a99 NONW14 IF continuation sheet 29 of 40 gency for Health Care Administration PRINTED: 04/05/2007 FORM APPROVED ATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA D PLAN OF CORRECTION IDENTIFICATION NUMBER: 33508 F PROVIDER OR SUPPLIER R3MC NURSING CENTER {X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 (X3) DATE SURVEY COMPLETED 03/30/2007 x4) 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 5) 'REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N.248|-Continued-Erom_page 29. N216 another resident. CNA #1 informed that nurses - are made aware of when this occurs. On 03/27/07, during a 4:56 PM interview with staff member CNA #2, regarding call bells/tights she revealed her assigned resident's have reported to her that they have been made to wait for care to be provided while she has been ona break or busy attending another resident. CNA #2 informed that nurse's are made aware of when this occurs. : Review of Resident Council minutes for 03/20/2007 revealed that call lights are "not answered in a timely manner or they (staff) will say I'll get your aid or I'll be right back and not come back", Review of the resident Grievance Log revealed on 03/20/2007 for the North, West and South wings that “Patient state that the call lights don't This plan of correction constitutes our credible allegation of compliance with licensure requirements. This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing contained herein shall be construed as an admission that the facility violated any federal or state regulation or ‘to follow any applicable standard of care. ——+-getansweredin-atimely_mannerand-when-the aides come they say they'll be right back and don't come back". The Follow-up section stated that 'Referred to charge nurse for follow up timing of CNAs to answer call lights". Interview with resident #9 on 03/26/2007 at 2:51 PM revealed “about a week ago had incontinent episode (bowel) in bed and it took 45 minutes to a hour to be cleaned". The resident stated that he/she is aware when he/she needs to have a bowel movement but had to wait but had the incontinent episode while waiting on the staff to assist. 13. Review of the facility's Nursing Standards Manual in the PREVENTION AND REPORTING OF RESIDENT ABUSE section under Purpose orm 3020-0001 FORM Beg NONW11 If continuation sheet 30 of 40 \TEMENT OF DEFICIENCIES > PLAN OF CORRECTION \ dP SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDER'S PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N216| Continued From-page-30 N216 - - ane ” . This plan of correction constitutes our credible ’ the facility defines Neglect as' The failure or allegation of compliance with licensure requirements. omission on the part of the caregiver to provide This platrof correction is being submitted pursuant to care, supervision and services necessary to _the appl icable Federal and state regulations, Nothing maintain the physician and mental health of “foncained herein shal be construed as an admission that + . an the facility vioiated any federal or state Tegulation or vulnerable adult, including but not limited to, food, failed to follow any applicable standard of care clothing, medicine, shelter, supervision, and medical services, that a prudent person would consider essential for the well-being of-a vulnerable adult. This term also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult form abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonable be expected to. result in serious physical harm or psychological injury or a substantial risk of death.", Class | Pattern Correction date: 4/12/07 }-400.4.47(4),_F.S_Incident-Report Use in Risk N942 | = I Mgmt Prograni The following identified residents 400 447 4 #22, #32, #33, #35, #34, and #15 147(4) were closed record reviews. Each internal risk management and quality Resident #28, #30, #3 lhave received assurance program shall include the use of subsequent accuchecks as ordered, incident reports to be filed with the risk manager documented on the New Diabetic and facility administrator. The risk manager shall ency for Health Care Administration MC NURSING CENTER (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 33508 ROVIDER OR SUPPLIER (X2) MULTIP! A, BUILDING B. WING PRINTED: 04/05/2007 LE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 {X3) DATE SURVEY COMPLETED 03/30/2007 FORM APPROVED have free access to all resident records of the licensed facility. The incident reports are part of the work papers of the attorney defending the licensed facility in litigation relating to the licensed facility and are'subject to discovery, but are not admissible as evidence in court. As part of the. each internal risk management -orm FORI and quality assurance program, the incident reports shall be used to develop categories of 3020-0001 M 6398 NO! MAR, and existing hypoglycemic protocols followed as per physician orders. Review of ordered medications for Resident #14, and #7 have determined that all medications are available for administration from the assigned medication cart.. NW 14 If continuation sheet 31 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration \TEMENT OF DEFICIENCIES 2 PLAN OF CORRECTION (X3) DATE SURVEY x (X1) PROVIDER/SUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING 33508 03/30/2007 \ F PROVIDER OR SUPPLIER MC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 x4) ID SUMMARY STATEMENT OF DEFICIENCIES : ID PROVIDER'S PLAN OF CORRECTION (x8) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N912| Continued Erom page 34 N942_ . a ; This plan of correction constitutes our credible incidents which identity problem areas. Once allegation of compliance with licensure Tequirements. identified, procedures shall be adjusted to correct This plan of correction is being submitted pursuant to the problem areas. the applicable Federal and state regulations. Nothing Contained herein shall be construed as an admission that the facility violated sty federal or state regulation or failed to follow any. applicable Standard of care. This Rule is not met as evidenced by: All residents have the potential of Based on record review, staff interviews the _ being affected. facility failed to file incident reports for medication errors for 11 of 38 (#22,28,30, Staff has been reeducated by the 32,35,34,33,14,15,7, and 31) records reviewed. Risk M. and/or designee in the Failure to file incident reports for medications Sh “abager a. ign errors places the residents at risk of not receiving utilization of existing incident needed care and services. . reporting system (midas) and to Findi place a call to Risk Management to i) Pineings: report all incidents. 1. Review of the medical record for Resident #22 ; . revealed the resident was admitted on DON and/or designee will speak 01/12/2007 with a diagnosis of Diabetes Mellitus. with Risk Manager weekly to discuss n-1/12/200/ bloods-sugatlevels (BS)-were- “thi € accurate and timely use of the ordered to be performed before meals and at bedtime. Included in the admission orders dated incident reporting system by nursing 1/12/07 was a protocol for the nursing staff to staff, Any failure to use the . follow in the event the resident's blood sugar reporting system will be noted and was low enough to warrant intervention. The .| Said staff person(s) will be counseled order dated 01/12/07 was listed as #3 of page two on the Physician Order Sheet (POS) and appeared as: _ . 4/12/07 Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (50 inject 1 amp) . accordingly. Review of the medical record for resident #22 revealed the following BS for the resident on orm 3020-0001 FORM . n99 NONW11 if continuation sheet 32 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X83) DATE SURVEY (<1) PROVIDER/SUPPLIERICLIA 1) wa COMPLETED (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A, BUILDING B. WING . 33508 03/30/2007 }PROVIDER OR SUPPLIER McC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 4) 1D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECTION (x5) 2REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE “AG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 1942} Continued From_page_32 N942_ : : ag m ts Plan Or correction constitutes our credible 01/16-17/07 with intervention performed by the Theor Of Compliance with licensure requirements, nurse is plan of correction is being submitted pursuant to a‘ | the applicable Federal and state regulations, Nothing 4/16/07 Comained herein shall be consirued as an admission that 3:00 PM-11:00 PM Nurse pateelity violated any federal or state tegulation or 1635=65, Glass of Apple juice “ted fo follow any applicable standard of care, 1740=97, No interventions 2026-66, Glass of Apple juice 11:00 PM -7:00 AM Nurse 2330=43, Two glasses of apple juices 01/17/07 0008=31, Two apple juices and two orange juices 0021=42, Health Shake and 3 instant oral glucose 0058=30, No interventions documented 0132=33, Attempted to start IV 0143=38, Resident cardiac arrest, expired. , Medical record review did not reveal that the physician was notified of the low BS. Interview with the 11:00 PM to 7:00 AM nurse on 3/29/2007 at 9:15 AM revealed "Did not do the protocol . because the health shakes usually work", When | ___|_as| ician was_not called the-nurse stated that "| never call the physicians but | would just sent the residents to the Emergency Room if needed.” Interview with the residents physician by telephone on 03/29/2007 at 9:00 AM revealed that he would have expected a telephone call from the 11:00 PM to 7:00 AM nurse for this resident concerning the low BS but I did not get one. Interview with the Director of Nursing (DON) on 03/29/2007 at 10:00 AM revealed that the medical record (unexpected death) was not reviewed as part of the quality improvement program. am 3020-0001 ‘ORM 8899 NONW11 If continuation sheet 33 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration ATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X8) DATE SURVEY > PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED NTIFICA A. BUILDING - 33508 8 WING 03/30/2007 ‘ ¥ PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST 2MC NURSING CENTER LEESBURG, FL 34748 X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N.9121 Continued From-page-33 | N942_ This plan of correction constitutes our credible 2. Observation of Medication pass for resident allegation of compliance with licensure requirements. #15 on 03/26/07 at 8:35 AM, revealed the This plan of correction is being submitted pursuant to medication, Zyvox (an antibiotic to treat the the applicable jeder and sate regulation. Nothing . . . contamed herein s| € construed as an admission that resident pneumonia) was not given, the the facility violated any federal or state regulation or medication nurse for this resident, stated the : failed to follow any applicable standard of care, medication was not available from pharmacy yet : and the resident has not received any doses yet Review of the Physicians orders reveals the Zyvox for resident #15 was ordered 03/23/07 at 10 PM. Interview 03/26/2007 at 8:35 AM with Medication nurse reveals she called the pharmacy and was told they would have the Zyvox for the 8 PM dose 03/26/07. 3. Observation of Medication pass for resident of #14 on 03/26 07 at 8:20 AM revealed that the medication nurse for this resident flipped the Medication Administration Record (MAR) over and wrote "Med out of stock ,has reorder". The medication nurse for resident #14 was questioned by this surveyor at this time. The Lactinex dose as they do not have the pill form as | ordered and that the resident will not take powdered form. Review of the MAR indicates the resident has not had Lactinex for 15 days. Record review revealed that on 3/21/06 12:00 noon the nurse wrote on back of MAR "Has been Teordered many times." 4, Record review for resident #31 revealed that the resident # 31 has a hypoglycemic protocol ordered on 03/13 /07, it reads as follows: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (50 inject 1 amp) Form 3020-0001 : FORM e599 NONW11 lf continuation sheet 34 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration ‘TEMENT OF DEFICIENCIES ) PLAN OF CORRECTION (X3) DATE SURVEY 1) PROVIDER/SUPPLIERYCLIA (x) COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 } PROVIDER OR SUPPLIER ~ STREET ADDRESS, CITY, STATE, ZiP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 4) ID SUMMARY STATEMENT OF DEFICIENCIES 1D. PROVIDER'S PLAN OF CORRECTION ‘MC NURSING CENTER (xs) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) \.912! Continued-From_page_34 N942. This plan of correction constitutés our credible allegation of compliance with licensure requirements. i it ' ‘i This plan of correction is being submitted pursuant to Review of resident #31's blood sugars for the the appliceble Federal and state regutations. Nothing month of March revealed that on 03/15/07 contained herein shall be construed as an admission that resident #31 had a Blood Sugar (BS) of 71, on "| the facility violated any federal or state regulation or 03/17/07 a BS of 52; on 03/19/07 a BS of 79, on failed to follow any applicable standard of care. 03/25/07 a BS of 68 and on 03/28/07 a BS of 67. Further review of the MAR in the Hypoglycemia protocol section revealed no entries to indicate the protocol had been followed. : 5. Closed record review for resident #35 revealed the resident was admitted 02/11/07 at 6:30 PM. Review of the MAR indicated an order for Rocephin (an antibiotic) not available 02/12/07 and 2/13/07 , Paxil (used to treat depression) not available on 02/12/07, Colace (stool softener) not available 02/13/07. No medications were on the i MAR were signed off as given until 02/13/07, 6. Closed record review for resident #34 revealed the resident was admitted to the facility on 02/11/07 at 5:00 PM. Review of the MAR | revealed Careg (for blood pressure)_and Zocor] (for cholesterol) not available 2/11/07, Amaryl (for Diabetes) not available 02/12/07, Evista (to prevent Osteoporosis), Avandia (for Diabetes), Zoloft (for depression), also not available. Colace (stool softener) not available on 02/13/07. Further review of the MAR reveals that resident #34 did not receive any medications until their 8:00 PM dose on 02/12/07, 7. Closed record review for resident #33 revealed the resident was admitted to the facility 02/03/07 | at 7:00 PM. Review of the MAR revealed a Calcium (a supplement) was not available 02/13/07, Seroquel (for psychotic disorders) was Not available 2/13/07, Namenda (Alzheimers treatment) was not available on 02/13/07. =orm 3020-0001 FORM 8899 NONW11 If continuation sheet 35 of 40 PRINTED: 04/05/2007 FORM APPROVED gency for Health Care Administration “ATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X3) DATE SURVEY COMPLETED (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING 33508 03/30/2007 YF PROVIDER OR SUPPLIER RMC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ; (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES JREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) -N-942/ Continu ed From page 35_ N912 | This plan of correction constitutes ourcredible—___| allegation of compliance with licensure Tequirements. This plan of correction is being submitted pursuant to the applicable Federal and statz regulations, Nothing contained herein shall be construed as an admission that the facility violated any federal or state tegulation or failed to follow any applicable standard of care, 8. Record review revealed Resident #28 was admitted on 7/25/05 with diagnosis including Diabetes Mellitus, Schizophrenia, Hypertension, and Psychotic Disorder. Review of the March 2007 Medication Administration Record (MAR) revealed blood sugar (accucheck) before meals and at bedtime. The resident had physician orders for Sliding Scale Insulin coverage with _ Novolin R Insulin as follows: Blood Sugar 200-249 give 2 units Blood Sugar 250-299 give 4 units Blood Sugar 300-349 give 6 units Review of the March 2007 MAR revealed the following blood sugars recorded at 200 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/1 = @6 AM of 209 3/4 @ 11:30 AM of 207 [3/10 @ 11:30 AM of 205 3/14. @ 11:30 AM of 225 3/18 = @11:30 AM of 234 3/20 @ 11:30 AM of 219 4:30 PM of 213 8:00 PM of 245 3/24. @ 11:30 AM of 260 3/25 = @ 11:30 AM of 230 3/26 @ 11:30 AM of 210. 3/27 = @ 8PMof227 In an interview with the Unit Manager on 3/29/07 at 12:10 PM, it was stated there was no proof whether nurses gave the insulin or not on those dates. There was no other place where the medication administration was typically charted. : FORM 6390 NONW11 {f continuation sheet 36 of 40 PRINTED: 04/08/2007 FORM APPROVED ency for Health Care Administration ATEMENT OF DEFICIENCIES D PLAN OF CORRECTION (X3) DATE SURVEY PROVIDERS (X1) PROVIDER/SUPPLIERICLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 * PROVIDER OR SUPPLIER MC NURSING CENTER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION. (X5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE ; DEFICIENCY) N912! Continued From page 36 N92 This plan of comection-constitutes-cur-eredible-————| —-____|__ allegation of compliance with licensure Tequirements. . This plan of correction is being submitted pursuant to 9, Record review revealed Resident #30 was . the applicable Federal and state regulations. Nothing readmitted on 3/1/07 with diagnosis including ; contained herein shall be construed as an admission that ; the facility violated any federal or stale regulation or Insulin Dependent Diabetes Mellitus (IDDM), failed to follow any applicable standard of care. CVA, Dysphagia and Decubitus. Review of the March 2007 MAR revealed blood sugar (accucheck) before meals and at bedtime. The resident had physician orders for Sliding Scale insulin coverage with Novolin R Insulin as follows: Blood Sugar 151-200 give 2 units Blood Sugar 201-250 give 4 units Blood Sugar 251-300 give 6 units Review of the March 2007 MAR revealed the following blood sugars recorded at 151 and above. There was no documentation on the MAR that insulin coverage was given at these times: 3/3 @ 11:30 AM of 151 3/4 @ 4:30 PM of 172 3/7 @8PM of 151 I 3/8 @ 4:30 PM of 210 3/9 @ 4:30 PM of 232 3/13 @ 8 PM of 192 3/16 @ 8 PM of 173 3/19 @ 4:30 PM of 174 3/20 @ 4:30 PM of 218 3/22 @ 4:30 PM of 232 3/25 @ 11:30 AM of 168 3/26 @ 11:30 AM of 161 Interview with the Unit Manager on 3/30/07 revealed no further documentation of insulin medication administration could be provided. 10. Record review revealed Resident #32 was admitted 2/4/07 at 7:30 PM, with physician medication orders for Preservision Softgels, take Form 3020-0001 ° FORM 6809 NONW114 lf continuation sheet 37 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration \TEMENT OF DEFICIENCIES > PLAN OF CORRECTION (X3) DATE SURVEY (X1) PROVIDER/SUPPLIER/CLIA COMPLETED IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 33508 03/30/2007 ij PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 {MC NURSING CENTER <4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N912} Continued Erom page 37. |.N.912 This plan of conection constitutes our credible . + . allegation of compliatice with licensure requirements. 1 capsule by mouth 2 times daily. Review of the This plan of correction is being submitted pursuant to MAR revealed the medication not given for either the applicable Federal and state regulations. Nothing dose on 2/5/07, and on order from the pharmacy contained herein shall be construed as an admission that ' : the facility violated any federal or state regulation or ici. failed to-follow any applicable stundard of care. Physician orders 2/5/07 were documented for : Resident #32 for Albuterol .83 mg/ml solution and Ipratropium BR .02% solution, use 1 unit of each in updraft every 8 hours. Review of the February 2007 MAR revealed the medications were not signed off as administered, on the following dates for the 11 PM dose: 2/5, 2/9, 2/13, 2/15, 2/16, 2/17, 2/18, 2/19, 2/20, 2/22, 2/23 and 2/24/07. There was no explanation documented by nursing on the MAR as to why the doses were omitted. In interview with the Director of Nurses (DON) at | 1:40 PM on 3/30/07, it was stated that it looked '| like Albuterol was omitted on those dates. No further documentation was provided. _|a4. Record review revealed Resident #7 was admitted on 3/13/07 with diagnosis of Esophage: Cancer, Status Post Radiation Treatment & Chemotherapy. Review of the MAR revealed physician orders on 3/13/07 for Morphine Sulfate 15 mg Tab SA, substitute for MS Contin 15 mg SA, take 3 tablets every 8 hours. On 3/18/07 the resident's 10 PM dose was omitted. The reason documented by nursing on the MAR was the "MS Contin was on order." On 3/19/07 the resident's 6 AM and 2 PM doses were omitted. The reason documented by nursing on the MAR for omission of the 2 PM dose, was the medication was "not available from the pharmacy." There was no explanation documented by nursing for the . omission of the 6 AM dose on 3/19/07. Review of the MAR documented physician orders dated 3/13/07, for Nystatin 100,000 U/ml orm 3020-0001 FORM S899 NONW11 If continuation sheet 38 of 40 PRINTED: 04/05/2007 FORM APPROVED ency for Health Care Administration \TEMENT OF DEFICIENCIES (X3) DATE SURVEY > PLAN OF CORRECTION X1) PROVIDER/SUP| RICLI ad pe A COMPLETED {X2) MULTIPLE CONSTRUCTION IDENTIFICATION NUMBER: A. BUILDING B. WING 33508 03/30/2007 ‘ | PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 700 NORTH PALMETTO ST LEESBURG, FL 34748 ¢MC NURSING CENTER <4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5) REFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) N912/ Continued From page 38 N 912 = suspension, swish & swallow, 1 teaspoon 4 times “This plan of correction constitutes our credible daily. On 3/25/07 the 12 noon, 4 PM, and 8 PM allegation of compliance with licensure requirements. doses were omitted. The reason documented This plan of correction is being submited pursuant to on the MAR for the omission at 12 noon and 4 the applicable Federal and state regulations. Nothing j containéd herein shall be construed as an admission that PM was the med "not available from pharmacy.” the facility violated any federal or state regulation or - There was no explanation documented by failed to follow any applicable standard of care. nursing for the omission of the 8 PM dose. Interview with the DON on 3/28/07 at 10:30 AM, revealed no further documentation could be provided for the omission of resident #7's medications. 12 Interview with the Risk Manager on 03/28/2007 at 9:10 AM revealed that medication errors, including medications ordered but not administered, are reportable incidents. Ask if any incident reports were filed in 2007 as a result of medication ordered but not given the Risk Manager stated none had. 13. Review of the facility's incident reports for id not reveal any reports relating to. a medications ordered but not administered to the : residents. 14. Review of the facility's Quality Improvement minutes for February 2007 revealed that the: facility was in the process of obtaining bids from outside pharmacies to replace the hospital pharmacy. Continued review of the Quality Improvement minutes for all 2007 did not reveal that the facility had discussed or developed and implemented any plans to immediately correct the delays in residents receiving medications in a timely manner. Class Ill Pattern Correction date: 04/30/07 Form 3020-0007 FORM ; aes NONW11 If continuation sheet 39 of 40 PRIN IED: 04/05/2007 ency for Health Care Administration FORM APPROVED ° \TEMENT OF DEFICIENCIES (X1) PROVIDERYSUI PPLIER/CLIA (X3) DATE SU! 3 RAN OF CORRECTION DR MIDER/SUPPLIERICLY (X2) MULTIPLE CONSTRUCTION (3) comPLeneY A. BUILDING B. WING — 33508 03/30/2007 | PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE %MC NURSING CENTER 700 NORTH PALMETTO ST LEESBURG, FL 34748 X4) ID SUMMARY STATEMENT OF DEFICIENCIES : 1D PROVIDER'S PLAN OF CORRECTION x5) REFIX AEACHE DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG ORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) This plan of correction constitutes our credible allegation of compliance with licensure requirements. ‘This plan of correction is being submitted pursuant to the applicable Federal and state regulations. Nothing contained herein shall be construed as an admission that the facility violated any federal or state regulation or. ; © failed to follow any applicable standard of care. Form 3020-0001 !FORM ; 6899 NONW/141 If continuation sheet 40 of 40 PRINTED: 04/05/2007 2PARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED INTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391 TEMENT OF DEFICIENCIES (1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION 3) OnE REY PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING 01 - MAIN BUILDING 04 col . 105621 8. WING 03/27/2007 ‘PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MG NURSING CENTER 700 NORTH PALMETTO ST LEESBURG, FL 34748 ‘41D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION 5) 2EFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG . CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) ~000-INIFIAL COMMENTS. . _ This pian of correction constitutes our credible * :allegation of compliance with licensure Tequirements. Noun os Safety Code Survey Conducted on | This plan of correction is being submitted pursuant to arch 27, 2007. ‘the applicable Federal and state regulations. Nothing | . Contained herein ‘shall be construed as an admission that: This Facility is compliance with all provisions of the facility violated any federal or state regulation or the applicable Fire and Life Safety Code - failed to follow any applicable standard of care. Requirements for this type of facility as of this . date and survey: Code references are as follows: Federal Regulations 2000 Edition NFPA 101-19, State Fire Marshal's Rules and Regulations 68A-03, 69A-38, 69A-46 and G9A-48 and 42 CFR Part 483 Subpart B. TORY DIRGCTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TILE... (KG) DATE = MY, $f Lip Ly $7] Paermaes way: sieney sfaten ent ending with an asterisk (*) denotes a deficiency which the institution may b¥ excused from correcting providing it is determined that ther ‘ds’previde sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the +” “swhether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date hts are made available fo the facility. !f deficiencies ara cited, an approved plan of correction is requisite to continued program participation. AS-2567(02-S9) Previous Versions Obsolete Event ID:NONW21 Facility iD: 33508 lf continuation sheet Page 1 of 1

Docket for Case No: 07-002865