STATE OF FLORIDA Q> 4 & AGENCY FOR HEALTH CARE ADMINISTRATION 4p <9 Ay ey Az, O 7 - db | 4 40, ie, 43 STATE OF FLORIDA, Wels Ppt, Or AGENCY FOR HEALTH CARE Ri Vip ADMINISTRATION, oS Petitioner, vs. Case Nos. 2007006197 (Fines) 2007006199 (Cond.) THE PARKS HEALTH CARE ASSOCIATES, LLC, d/b/a PARKS HEALTHCARE & REHABILITATION 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 THE PARKS HEALTH CARE ASSOCIATES, LLC, d/b/a PARKS HEALTHCARE & REHABILITATION 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 ending April 4, 2007, impose an administrative fine in the amount of $20,000.00 and a survey fee in the amount of $6,000.00, based upon Respondent being cited for two State Class I deficiencies. JURISDICTION AND VENUE 1. 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. 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 9311 S. Orange Blossom Trail, Orlando, FL 32837, and is licensed as a skilled nursing facility license number 1089096. 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. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Florida law, each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A preliminary nursing evaluation with physician’s orders for immediate care, completed on admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment. R. 59A-4.109(1), Florida Administrative Code. 8. That on or about March 30, 2007, the Agency conducted a Complaint Survey (CCR #2007003182) at Respondent’s facility. 9. That based upon observation, the review of records, and interview, Respondent failed to follow and revise care plans for four (4) of seven (7) sampled residents regarding the use of wander guards, the same being contrary to law. 10. That resident number one (1) eloped from the Respondent facility undetected on March 2, 2007. 11. That the Petitioner’s representative reviewed the Respondent’s records regarding resident number one (1) during the survey of Respondent, and noted the following: a. That the resident's hospital history and physical, dated February 2, 2007, indicated the chief complaint for hospitalization as"... altered mental status. ... while in the assisted living facility and was brought to the emergency room for evaluation." Psychiatric consultation documented that the resident "... has mild dementia;" b. That Respondent’s nursing data collection completed February 27, 2007 upon the resident’s admission read, "Behavior - Wanders" and described behaviors as "Wandering, Anxiety" with an "Elopement Risk - Cognitively impaired with high physical functioning;. c. That progress notes indicated the following: 2/27/07 at 4 p.m. "Resident answers to name, confusion noted." 2/27/07 at 7:30 p.m. "Resident wandering, walking the hallway." 2/28/07 at 3 a.m. " Pleasant but confused. Wandering in residents’ rooms. 2/28/07 at 11 a.m. "Noted anxiety and agitation.” 3/01/07 at 6 a.m. "Periods of confusion and disorientation.” 3/01/07 at 3 p.m. "Confusion noted." 3/02/07 at 10:40 a.m. "Confusion noted." 3/02/07 at 6:50 p.m. "Resident eating dinner in TV room with family assisting. Alert with confusion noted.” 3/02/07 at 7:20 p.m. "Received call from sheriff that resident was found the elderly female/male at Burger King across the street.” " d. The care plan for the resident dated March 2, 2007 indicated the resident's potential for recurrence of elopement, and poor cognition and judgement/safety awareness; e. A wander guard was placed on the resident's right (R) ankle and the elopement risk alert indicated "wander guard right ankle". f. That the resident’s Minimum Data Set (MDS) admission 5 day assessment, with an assessment review date (ARD) of March 6, 2007 and completion date of March 7, 2007, and the 14 day assessment with an ARD of March 12, 2007 and completion date of March 13, 2007 both indicated memory of short and long term memory problems and cognitive skills for daily decisions-making is severely impaired/never/rarely made decisions. 12. _ That the Petitioner’s representative reviewed the sheriff's report dated March 2, 2007 noted at 7 p.m. which indicated as follows: "I responded to Consulate drive and South Orange Blossom Trail in reference to a disoriented elderly [person]. When I arrived an anonymous female said she had helped this [person] across the road. I made contact with the elderly [person], later identified as [resident number one (1)]. [The resident] was unsure what [his/her] name was or where [s/he] was at. I asked [him/her] if [s/he] knew where [s/he] lives and [s/he] said, ‘No.’” 13. That the Petitioner’s representative observed resident number one (1) on March 28, 2007 at 11:15 a.m. and noted the following: a. That the resident was in the TV room disengaged in TV; b. That the wander guard was not observed on the right ankle but was on the left arm, c. That the resident was not encouraged by staff to attend the "Starlight Program" for elopement at risk residents which was in progress at that time with the goal of the program for those residents at risk for elopement to keep the residents under constant supervision. 14. That the Petitioner’s representative observed resident number one (1) on March 28, 2007 at approximately 5 p.m. and noted the resident sitting on the right side of the bed talking on the phone with the wander guard not seen on the right ankle but on the left wrist. 15. That the Petitioner’s representative interviewed the Respondent’s risk manager on March 28, 2007 who indicated as follows: a. That the staff who remove and place the resident's wander guard to a new location must communicate that to the risk manager to ensure the plan of care is updated; b. That the "...resident [was] not talking to anyone. [S/he] does this all the time." The resident was not accurately assessed to be an elopement risk before eloping/exiting the facility undetected by staff. 16. That the Respondent failed to accurately assess the resident number one (1) as an elopement risk based upon the resident’s prior history and behaviors and took no action to address the risk until after the resident’s elopement on March 2, 2007. 17. That the Respondent failed to revise the care plan regarding the use of a wander guard device where the same was not being utilized in accord with the plan of care. 18. That the Petitioner’s representative reviewed Respondent’s records regarding resident number four (4) on March 30, 2007 and noted the following: a. That the resident’s care plan dated January 25, 2007 indicated elopement risk/poor memory, diagnosis anxiety, and at times has gone to look for exit to go home, wanders about in wheelchair; That approaches included a wander guard to the right (R) ankle and to take the resident to small group activities. The resident was observed on 3/28/07 at 11:15 a.m. in the TV room but not watching TV. The wander guard was not on the right ankle but was seen on the left arm. The resident was not encouraged by staff to attend the "Starlight Program" for residents which was in progress at that time. One of the goals of this program, according to the facility, 1s to "keep . . . residents alert, busy, and out of problems.” 19. That the Petitioner’s representative observed resident number four (4) on March 28, 2007 at 11:15 a.m. and noted the following: a. b. That the resident was in the TV room but was not watching TV; That the wander guard was not observed on the right ankle but was on the left arm; That the resident was not encouraged by staff to attend the "Starlight Program" for elopement at risk residents which was in progress at that time with the goal of the program for those residents at risk for elopement to keep the residents under constant supervision. 20. That the respondent’s stated purpose of the “Starlight Program” is to "keep . . . residents alert, busy, and out of problems.” 21. That the Petitioner’s representative interviewed Respondent’s risk manager on March 28, 2007 who indicated that staff who remove and place the resident's wander guard to new location must communicate this information to the risk manager to ensure the plan of care is updated. 22. That the Respondent failed to revise the care plan regarding the use of a wander guard device where the same was not being utilized in accord with the plan of care and where planned activities to enhance resident supervision were not followed. 23. That the Petitioner’s representative reviewed Respondent’s records regarding resident number two (2) during the survey and noted as follows: a. That the resident’s care plan dated March 21, 2007 required that the resident wear a wander guard on the right wrist; b. That the resident’s case plan required that staff conduct location rounds. 24. That the Petitioner’s representative observed resident number two (2) on March 28, 2007 and noted the following: a. That at 11:15 AM in the facility dining room, the resident was observed without a wander guard; b. That at 5:00 PM the resident was observed in the facility without a wander guard; c. That the Respondent’s risk manager searched the resident for the wander guard device and could not locate the same; d. That the respondent’s risk manager asked the resident where the wander guard was located and the resident could not provide the information. 25. That the Petitioner’s representative interviewed the Respondent’s risk manager on March 28, 2007 who indicated as follows: a. That resident number two (2) should have a wander guard on the wrist; b. That she could not explain why the wander guard was not in place; c. That the resident had been assessed as having an elopement history; d. That she could not explain the lack of documentation to support that location rounds had been conducted. 26. That the Petitioner’s representative interviewed the Respondent’s unit clerk on the East wing on March 30, 2007 who indicated that she had seen the wander guard on her desk but did not know how it got there. 27. That the Petitioner’s representative reviewed Respondent’s documentation of the conduct of location rounds and noted that the rounds were not consistently being documented by the 3-11 p.m. shift as required by the care plan in that location rounds are not documented thereon for March 23, 24, 25, 26, or 28, 2007. 28. That the Respondent failed to revise the care plan regarding the use of a wander guard device where the same was not being utilized in accord with the plan of care and where planned location rounds were not conducted as planned. 29. That the Petitioner’s representative observed resident number ten (10) on March 28, 2007 in the "Starlight Program" and noted that the resident was wearing a wander guard on the left ankle. 30. That the Petitioner’s representative reviewed Respondent’s records regarding resident number ten (10) during the survey and noted that the resident was to wear a wander guard on the right wrist and that the resident’s location be documented by the 3-11 shift. 31. That the Petitioner’s representative reviewed the Respondent’s documentation regarding the documentation of the location of resident number ten (10) for the 3-11 shift and noted that the same had not been documented until March 28, 2007. 32. That the Respondent failed to revise the care plan regarding the use of a wander guard device where the same was not being utilized in accord with the plan of care and where planned location monitoring was not conducted or documented. 33. That the Petitioner’s representative interviewed Respondent’s risk manager on March 29, 2007 who could not explain why the elopement protocols identified above as in place for the protection of residents were not being followed consistently. 34. That this action or inaction of the Respondent and its failure to develop care plans for residents in a timely manner is in violation of Florida law. 35. | 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 a State Class I deficiency. 36. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 3, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2006). COUNT II 37. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 38. 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). 39. That Florida law provides that all licensees of nursing home 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 following...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...the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints... § 400.022, Florida Statutes (2006). 40. That on or about March 30, 2007, the Agency conducted a Complaint Survey (CCR #2007003182) at Respondent’s facility. 41. That based upon observation, the review of records and interview, Respondent failed to provide appropriate health care and protective and support services including, but not limited to, supervision and assistive devices to prevent a wandering cognitively impaired residents from eloping/exiting the facility undetected by staff for one (1) of eleven (11) sampled residents and failed to accurately implement the systems in place to prevent elopement of at-risk residents with dementia. 42. That the Petitioner’s representative reviewed the clinical record of resident number one (1) and noted that the resident had eloped from the Respondent facility undetected at approximately 6:45 PM on March 2, 2007. 43. That the Agency re-alleges and incorporates paragraphs eleven (11) (a), (b), (c), and (f), as if fully set forth herein. 44. That the facility’s main door requires the entry of a code number in a key pad to activate the doors. 45. That the Petitioner’s representative reviewed the sheriff’s report regarding the elopement of resident number one (1) dated March 2, 2007 at 7:00 PM and noted the following: a. I responded to Consulate Drive and South Orange Blossom Trail in reference to a disoriented elderly [person]. When I arrived, an anonymous female said she had helped this [person] across the road. I made contact with the elderly [person], later identified as [resident number one (1)]. [The resident] did not know [h/is/her] name was or where [s/he] was. I asked [the resident] if [s/he] knew where [s/he] lived and [s/he] said, "No." [The resident] was transported back to the facility where I met with [his/her] nurse who ... said the resident was eating dinner with [his/her] family and she did not notice the resident went missing until the sheriffs office contacted her. The nurse said all the doors in the facility should be alarmed. b. This Burger King restaurant is approximately one quarter mile north from the facility. In order to reach it, the resident had to walk across State Road (SR) 441/Orange Blossom Trail. This SR is extremely busy and used by both cars and semi-trucks. Also, SR 441/Orange Blossom Trail has roads with very heavy traffic leading to and from two major highways, the Florida Turnpike and SR 428. 46. That the Petitioner’s representative interviewed the Respondent’s risk manager on March 28, 2007 regarding the facility’s investigation of the resident’s elopement and noted as follows: e. That she made a time line of events based on the charge nurse on duty and the certified nursing assistant (CNA) who was assigned to care for the resident before the resident eloped from the facility undetected by staff; That her investigation indicated that the resident left the building on March 2, 2007 at approximately 6:45 p.m.; That at 7 p.m. on March 2, 2007, the police called the facility stating the resident was found across the street at Burger King; That a facility CNA went to the Burger King and escorted the uninjured resident back to the facility; . That at that time, elopement procedures were then implemented for this resident. 47. That the Petitioner’s representative toured the Respondent facility on March 28, 2007 at 10:20 AM and noted as follows: a. b. That on the East wing, resident number one (1) was noted in his/her room, 64 A; That the resident’s bed was close to the door of the room; That the room was near the hallway further away from the nurse’ station; That this room is very close to two exits which lead to the outside of the facility; That the doors alarm when open but do not have the capability to activate the alarms associated with the wander guard alarm system; That both doors are further away from the nurses' station; That the only door alarmed to activate the wander guard system is the front door; That the hallway on the East wing's back entrance is totally out of site from the nurses' station; That this exit is close to the physical therapy (PT) department, but the doors are 12 closed during working hours while PT provides resident service; That after working hours, PT staff is not present on this back hall; That both doors lead to the outside into the facility's parking lot which has a large amount of incoming and outgoing traffic and where staff, family and visitors park; That this road from parking lot leads to another narrow lane road that has a blind spot when making a left turn and then curves out into the major heavy traffic on North and South SR 441/Orange Blossom Trail; That at approximately 7:15 PM., a staff member from PT gave out the code to exit the back entrance; That after the code was entered, the left door was opened and remained open for approximately three minutes before the door alarm sounded. 48. That the Petitioner’s representative interviewed the Respondent’s maintenance director on March29, 2007 by phone who indicated as follows: a. b. Cc. When asked why there was a delay in the East wing back entrance door's alarm? He said, "I don't know if anyone told you. . . [but]. . . the alarm can be manually altered by me. I normally delay the alarm for 20 to 25 seconds. This is the door we get most of the supplies delivered and the delivery guy sometimes has up to three pallets to bring inside and that alarm just keeps going off;” That the delivery person is given the code; That all family and visitors are given the code. 49. That the Petitioner’s representative interviewed on March 29, 2007 the Respondent’s 3- 11 charge nurse who was on duty at the time of the elopement of resident number one (1) who 13 indicated as follows: a. That she gave her residents their medication, including resident number one (1); b. That she knew it was a Friday, the 1st or 2nd day of March 2007; Cc. That while giving resident number one (1) medication, the family visited with the resident in the resident’s room; d. That after receiving the medication, the resident and family went out to the TV area on the unit; e. That the resident ate dinner in the TV room with family around 5:30 or 6 p.m.; f. That after supper, the family requested permission to take the resident outside for some fresh air; g. That the nurse told the family they could as long as they were with the resident at all times and were to bring the resident back inside before they left; h. That she thought they left the unit from the front main front entrance door; i. That she observed the family bring the resident back into the facility about 6:30 p.m. to the TV area and they remained with the resident; j. That she did not remember how long the family remained with the resident because she was caring for other residents at that time; k. That two other 3-11 nurses were also providing care to other residents at that time; 1. That she received a telephone call from the sheriff notifying her that they found the resident across the street at Burger King; m. That immediately two CNAs volunteered to get the resident and both CNAs left in their car and brought the resident back to the facility unharmed; 14 n. That she did a skin assessment of the resident and "found nothing, vital signs, everything was good;" Oo. That she asked the resident how s/he got out, but the resident replied, "I don't know;" p- That when asked to describe an adverse incident, she answered "Behaviors, I don't know.” 50. That the Petitioner’s representative interviewed on March 29, 2007 Respondent’s 3-11 shift CNA who was on duty during the time of the elopement of resident number one (1) who stated the following: “All I know, the phones were ringing and I was asked do we have a patient here by the name of [resident #1]. I was not for sure because [s/he] is fairly new, so I told the charge nurse and she verified the resident belonged to us. I and another CNA took my car over to Burger King and the resident was there outside in the parking lot with the fire department. A question was asked did the resident belong to us. We put the resident in the car. The sheriff's department was there and stated they would be over to the facility. I want to say it was a Friday. I can't remember the time. I observed the resident earlier around dinner time sitting in the day room with family and that was the last time I really noticed [him/her] until I received the phone call from the sheriff's department.” 51. That the Respondent knew or should have known that resident number one (1) was at risk to elope from the facility and had noted the same in its initial assessment. 52. That the Respondent had a duty to protect resident number one (1) from elopement and breached that duty. 53. That the Respondent failed to provide protective and supportive services, inter alia, in its failure to implement procedures to prevent the resident from elopement, failure to place the resident in an area with adequate supervision, failure to ensure that doors were appropriately alarmed and or that such alarms were responded to, failure to ensure key pad codes protected residents by both the limitation of the provision of said codes to individuals or assurances that doors, when opened, closed without risk of resident elopement. 54. That these actions or inactions of the Respondent are a failure to provide adequate and appropriate health care and protective and support services entrusted to the Respondent’s care and is contrary to law. 55. 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 a State Class I deficiency. 56. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 3, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 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 57. The Agency re-alleges and incorporates Counts I and II of this Complaint as if fully set forth herein. 58. Respondent has been cited for two (2) 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 (2005). COUNT IV 59. The Agency re-alleges and incorporates Counts I and II of this Complaint as if fully set forth herein. 60. Based upon Respondent’s two 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)(b), Florida Statutes (2006). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2006) commencing March 30, 2007 and ending April 4, 2007. Respectfully submitted this / 7 day of July, 2007. c4 Lye bs fnas’J. Walsh, II, Esquire /€1d. Bar. No. 566365 ' Agency 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), Fla. Stat. (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 a right 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, (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT OR WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No: 7005 1160 0002 2254 9013 on July /O_,2007 to: Eloise Abrahams, Administrator, Parks Healthcare & Rehabilitation Center, 9311 S. Orange Blossom Trail, Orlando, FL 32837 and by U.S. Mail to Corporation Service Company, Reg. Agent, 1201 Hays Street, Tallahassee, FL 32301-2525. Thomas’ | Walsh, IL, Esquire off ff Copies furnished to: Eloise Abrahams, Administrator Parks Healthcare & Rehab Center 9311S. Orange Blossom Trail Orlando, FL 32837 (U.S. Certified Mail) Corporation Service Company Registered Agent 1201 Hays Street Tallahassee, FL 32301-2525 (U.S. Mail) Joel Libby Field Office Manager Hurston South Tower 400 W. Robinson, Suite S309 Orlando, FL 32801 (U.S. Mail) Thomas J. Walsh, IL, Esquire Senior Attorney Agency for Health Care Admin. 525 Mirror Lake Dr, 330G St. Petersburg, Florida 33701 Cnteroffice)

Docket for Case No: 07-003616