STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, OT . UY Y iW AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, Case Nos. 2007007929 (Fine) vs. 2007007930 (CL) SOVEREIGN HEALTHCARE OF METRO WEST, LLC d/b/a METRO WEST NURSING AND REHAB 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 SOVEREIGN HEALTHCARE OF METRO WEST, LLC d/b/a METRO WEST NURSING AND REHAB CENTER, (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of TWO THOUSAND DOLLARS ($2,000.00) pursuant to Subsection 400.23(8)(c), Florida Statutes (2006), based upon two uncorrected class III deficiencies and assign conditional licensure status beginning on June 7, 2007, and ending on June 28, 2007, pursuant to Subsection 400.23(7)(b), Florida Statutes (2006). The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. JURISDICTION AND VENUE 1, The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2006). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Part II, Florida Statutes (2006). 3. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code (2006). PARTIES 4. The Agency is the regulatory authority responsible for the licensure of skilled nursing facilities and the enforcement of all applicable federal and state statutes, regulations and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes (2006) and Chapter 59A-4, Florida Administrative Code (2006). The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121, and 400.23, Florida Statutes (2006); assign a conditional license pursuant to Section 400.23(7), Florida Statutes (2006); and assess costs related to the investigation and prosecution of this case pursuant to section 400.121, Florida Statutes (2006). 5. Respondent operates a 120-bed nursing home, located at 5900 Westgate Drive, Orlando, Florida 32835, and is licensed as a skilled nursing facility, license number 16240961. 6. Respondent was at all times material hereto, a licensed skilled nursing facility under the licensing authority of the Agency, and was required to comply with all applicable state rules, regulations and statutes. COUNTI The Respondent Failed To Ensure A Comprehensive Care Plan For Each Resident In Violation Of Rule 59A-4,109(2), Florida Administrative Code (2006) 7. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6). 8. Pursuant to Florida law a skilled nursing facility is responsible to develop a plan of care —————=——— ts” which shall consist of, inter alia, 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 reviewed promptly after a significant change in the resident’s physical or mental condition and revised as appropriate to assure the continued accuracy of the assessment. Rule 59A-4.109(1), Florida Administrative Code (2006). 9. Pursuant to Florida law, a skilled nursing facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment. Rule 59A- 4.109(2), Florida Administrative Code (2006). 10. A “Resident care plan” means @ written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident, the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being; a listing of services provided within or outside the facility to meet those needs and an explanation of service goals. Section 400. 021(17) Florida Statutes (2006). 11. On ot about April 23, 2007 through April 26, 2007, the Agency conducted an Annual Survey at Respondent’s facility. 12. Based on observation, interview and record review, the facility failed to ensure that care plans for coumadin therapy and contractures were implemented for two (2) of twenty two (22) sampled residents, Residents number thirteen (13) and eighteen (18). 13. A review of the chart of Resident number thirteen (13) revealed the resident had diagnoses of cerebral vascular accident and hemiplegia. A review of the medications for the resident on the physician's order sheet dated April 1, 2007 revealed the resident received 10 mg. of coumadin at night and 7 mg. every day. A review of the physician's order sheet dated April 1, 2007 revealed the resident also received 81 mg. of aspirin every day. 14. A review of the care plans for Resident number thirteen (13) at 11:15 a.m. on April 23, 2007 revealed the resident did not have a care plan for coumadin therapy. An interview with the care plan coordinator at 11:30 a.m. on April 23, 2007 confirmed that the resident did not have a care plan for coumadin therapy. The care plan coordinator stated that the resident had recently been care planned and the care plan committee had discussed the coumadin therapy issue. The care plan coordinator stated that the facility had neglected to follow through with the coumadin therapy care plan. 15. A review of hospice Resident number eighteen’s (18) restorative nursing notes for February 2007 revealed that the resident received passive range of motion exercises and wore leg splints to both lower extremities due to leg contractures. A review of Resident number eighteen’s (18) comprehensive care plans revealed that there was no care plan that addressed decreased leg range of motion and contractures. 16. An observation of Resident number eighteen (18) on April 25, 2007 at 10:30 a.m. revealed that the resident had leg contractures and wore splints to both lower legs. 17. An interview with the Minimum Data Set coordinator on April 25, 2007 at 12:00 p.m. confirmed that there were no comprehensive care plans that addressed Resident number eighteen’s (18) leg contractures and range of motion needs. She stated that was because the Minimum Data Set had been incorrectly coded as "0", which indicated that there were no range of motion issues. The Resident Assessment Protocols did not trigger for consideration of the care plan to be initiated. She stated that the resident should have a care plan for the contractures/range of motion issue. She stated that the resident had been admitted to the facility with leg contractures. 18. The Agency determined that this deficient practice will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. The Agency cited the Respondent for a class III deficiency as set forth in Section 400.23(8)(c), Florida Statutes (2006). 19. Aclass HI deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. 20. The Agency provided Respondent with a mandatory correction date of May 23, 2007. 21. On or about June 6, 2007, through June 7, 2007, the Agency conducted a revisit to the Annual Survey of Respondent in conjunction with revisit to Complaint Investigation #2007004017. 22. Based on observation and interview, the facility failed to ensure that the care plan for unsafe smoker was implemented for 1 of 14 sampled residents, Resident number four (4), and failed to individualize a smoking care plan for resident to keep tobacco and lighter in his/her possession for 1 of 14 sampled residents, Resident number seven (7). 23. On June 6, 2007 at approximately 11:35 a.m., Resident number four (4) was observed outside in the courtyard (designated smoking area) with a pack of cigarettes and a lighter smoking alone. 24. An interview with Resident number four (4) on the above date and time revealed he/she got the cigarettes and the lighter from one staff member. 25. A review of the care plan for cigarette smoking dated May 10, 2007 and revised May 24, 2007 revealed that Resident number four (4) was to comply with the smoking policy, procedures and restrictions. The care plan indicated that the resident was to be supervised when smoking. The care plan indicated the resident was restricted to direct supervision when smoking. 26. An interview with the Director of Nursing on June 6, 2007 at approximately 12:00 p.m. revealed that Resident number four (4) needed direct supervision while smoking. 27. An interview with Resident number seven (7) on June 6, 2007 at approximately 10:15 a.m. revealed he/she kept tobacco and a lighter in his/her room. The resident indicated he/she was able to safely keep these items in his/her possession. 28. A review of the quarterly resident data set dated January 12, 2007 revealed that Resident number seven (7) was alert with no memory or cognition problems. 29, The care plan for smoking dated July 26, 2006 and revised on October 24, 2006, January 23, 2007, March 13, 2007, and April 17, 2007 indicated that all smoking materials were to be maintained at a designated place at the nurse's station. The care plan did not indicate that Resident number seven (7) was able to keep smoking materials in his/her room. 30. During an interview on June 6, 2007 at approximately 1:20 p.m., the administrator and the Director of Nursing confirmed the care plan for smoking failed to indicate that Resident number seven (7) was able to safely keep tobacco and lighters in his/her possession. 31. | The Agency determined that this deficient practice will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. The Agency cited the Respondent for a class III deficiency as set forth in Section 400.23(8)(c), Florida Statutes (2006). 32. Acclass Ill deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. 33. Based upon the above findings, the Respondent’s actions, inactions or conduct constituted an uncorrected class III deficiency pursuant to section 400.23(8)(c), Florida Statutes (2006). 34. | The Agency provided Respondent with a mandatory correction date of June 29, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Sections 400.23(8)(c) and 400.102, Florida Statutes (2006). COUNT II Respondent Failed To Ensure The Right To Adequate And Appropriate Health Care Services Were Provided In Violation Of Section 400.022(1)(1) Florida Statutes 35. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6), as if fully set forth herein. 36. 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 rules as adopted by the agency. Section 400.022(1)(1), Florida Statutes (2006). 37. A “Resident care plan” means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident; the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being; a listing of services provided within or outside the facility to meet those needs and an explanation of service goals. Section 400. 021(17) Florida Statutes (2006). 38. Based on observation, record review and interview, the facility failed to ensure adequate and appropriate health care services were provided for treatment to a surgical site and failed to assess pain for one (1) resident, Resident number three (3); failed to ensure dietary recommendations were followed for one (1) resident with low albumin levels Resident number nine (9), and failed to assess pain for one (1) resident, Resident number ten (10). The sample size was (22) twenty- two residents. 39. A review of Resident number three’s (3) diagnoses included post operative circumcision due to phimosis, balanitis, osteoarthritis to the left shoulder and degenerative joint disease. The admission on March 30, 2007 Minimum Data Set indicated the resident had no short or long term memory problems and was independent in cognitive skills and decision making. 40. The physician's order sheet of Resident number three (3) dated April, 2007 indicated to treat the surgical site daily with polysporin antibiotic ointment until healed and administer the pain medication Vicodin 5/500 1 tablet by mouth every 6 hours as needed for pain. 41. Resident number three (3) was interviewed on April 23, 2007 at 7:13 a.m. and stated treatment to the area was not being done consistently as ordered by the physician. The resident stated he/she was aware pain medications had to be requested. The resident stated at times he/she would request the pain medication and was informed by the nurse he/she received it earlier mixed with other morning medications. The resident stated when the nurse did this, the nurse failed to inform him/her the pain medication was being given. The resident was asked if nurses, prior to administering the pain medication, consistently ask where the location of the pain was and how intense the pain was and he/she stated "no". The resident was asked if the pain medication alleviated the pain and he/she stated, "not all the time". The resident was asked if nurses, after administering the pain medication, consistently inquired if the pain medication was effective and he/she stated "no". The resident stated at times when the pain medication was requested, he/she would have to wait a long period of time until the nurse administered the medication. 42. A review of the March, 2007 and April, 2007 medication administration records reflected the dates and times the pain medications were administered, but failed to identify consistently the location of the pain, intensity of the pain and the effectiveness of the pain medication after it was administered. 43. The facility's Pain Assessment Policy and Procedure SHC RC2 0002.2 and Resident number three’s (3) March 25, 2007 Documentation Tool sheet were reviewed. 44. On the Pain Assessment Policy and Procedure, under the title Purpose, it indicated the assessment includes the frequency and intensity of signs and symptoms of pain and can be used to identify indicators of pain as well as to monitor a resident's response to pain management interventions, It also attempts to target the site of pain. Under the section entitled Fundamental Information, it indicated a full assessment of pain includes origin, location, severity, alleviating, exacerbating factors, current treatment and response to treatment. Under the section entitled Procedures, it indicated: 2. ask resident to describe the pain, 3. observe resident for indicators of pain, 5. ask resident and observe to determine the frequency of pain, 6. ask the resident and observe to determine the intensity of pain and 7. ask the resident and observe to determine the location of pain. 45. | Areview of the Documentation Tool sheet identified under the section entitled Pain is used to determine location, description and quality of pain; score pain intensity according to 0-10 scale, precipitating factors, effects of pain, results of pain medication given, and other modalities used to relieve pain and pain assessment. 46. The Director of Nursing was interviewed on April 25, 2007 at 2:30 p.m. and confirmed the findings. The Director of Nursing stated the facility's Pain Assessment Policy and Procedure was not being followed. The Director of Nursing stated Resident number three (3) failed to have a consistent, complete and comprehensive pain assessment done each time the as needed pain medication was administered. 47. A review of the March, 2007 and April, 2007 treatment administration record indicated the treatment to the surgical site was not done as ordered on March 26, 2007; March 27, 2007; March 28, 2007; March 29, 2007; March 30, 2007; April 6, 2007; April 8, 2007; April 9, 2007; April 10, 2007; April 11, 2007; April 13, 2007; April 17, 2007; April 19, 2007 and April 22, 2007, for a total of 14 days. 48. A review of the March 23, 2007 nursing Admission Resident Data Set failed to identify the surgical site under the section P, Skin and failed to identify under the section entitled Skin Treatments that the resident required surgical wound care. The Weekly Skin Measurement Tool was reviewed and indicated the surgical site was assessed one time on April 16, 2007. All the nurses’ notes were reviewed from the time of admission on March 23, 2007 until April 22, 2007. Assessment of the surgical site was not documented. 49. The wound nurse was interviewed on April 24, 2007 at approximately 11:45 a.m. and confirmed the findings. 50. The results of Resident number nine’s (9) laboratory albumin blood levels on March 7, 2007 and March 27, 2007 were reviewed. The normal albumin range identified on the laboratory shects were 3.2-5.5. The March 7, 2007 albumin result was low registering 2.4 and the result on March 27, 2007 was lower registering 2.1. 51. The dietician's recommendation to increase the albumin level was documented on the April 11, 2007 Nutritional Progress Notes. The dietician recommended increasing the Prosource/protein supplement thirty (30) cubic centimeters to two (2) times a day. Physician's orders were not found to reflect the dietician's recommendation. 52. The unit nurse manager was interviewed on April 24, 2007 at 11:20 a.m. and confirmed the physician was not notified of the dietician's recommendation and no physician's order was obtained to increase the Prosource to two (2) times a day. 53. A review of Resident number ten’s (10) medical record revealed diagnoses which included intractable low back pain. A review of the resident's Minimum Data Set dated March 15, 2007 coded the resident as having moderate pain on a daily basis. 54. A review of the medical record revealed that the resident received pain medications on a scheduled daily basis and also as needed for break-through pain. The April 2007 medication administration record revealed that from April 1, 2007, to April 23, 2007, the resident received two 5/325 mg. tablets of Percocet by mouth three times a day and one 50 mg. tablet of Ultram by mouth three times a day. 55. A continued review of the medication administration record revealed that the resident had orders to receive the following break-through pain medications as needed: One 5/325 mg. tablet of Oxycodone with acetaminophen by mouth every six (6) hours for moderate to severe pain and two 325 mg. tablets acetaminophen by mouth every four (4) hours as needed for mild pain. Oxycodone was administered on four (4) occasions from April 1, 2007 to April 23, 2007: April 1, 2007; April 2, 2007; April 3, 2007 and April 17, 2007. However, there was no pain assessment documentation that described the type of pain, the location of the pain, and the severity level of the pain prior to and after the administration of the medication. 56. A review of the facility's Pain Assessment Policy and Procedure revealed that an assessment of pain should include the location of pain, the type of pain, the severity of the pain, and the resident's response to the pain medication. 57. An interview with the Resident number ten’s (10) medication nurse and unit manager on April 24, 2007 at 2:00 p.m. confirmed the findings and that the nurse had not assessed and documented the resident's pain per the facility's Policy and Procedure. 58. | The Agency determined that this deficient practice will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. The Agency cited the Respondent for a class III deficiency as set forth in Section 400.23(8)(c), Florida Statutes (2006). 59. Acclass III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. 60, The Agency provided Respondent with a mandatory correction date for this deficient practice of May 23, 2007. 61. On or about, June 6, 2007, through June 7, 2007, the Agency conducted a revisit to the Annual survey of Respondent in conjunction with revisit to Complaint Investigation #2007004017. 62. _ Based on observation, record.review and interview, the facility failed to ensure adequate and appropriate health care services were provided for two (2) of ten (10) sampled residents with pressure ulcers, Residents number two (2) and number nine ( 9); for one (1) of four (4) smokers, Resident number four (4), and for two (2) of three (3) sampled residents receiving intravenous therapy, Residents number ten (10) and number fourteen (14), in a total sample of fourteen (14) residents. 63. Areview of totally dependent and comatose Resident number two’s (2) weekly pressure ulcer assessment documentation dated June 7, 2007 revealed he/she had a stage IV coccyx pressure ulcer measuring 10 cm. in length, 4.5 cm. in width and 0.9 cm. in depth. 64. A review of the physician's telephone orders for Resident number two (2) revealed a pressure ulcer treatment order dated April 25, 2007 as follows: "Coccyx wound: Cleanse with wound cleanser, apply skin prep to peri-wound, apply Accuzyme to wound bed, fill with fluffed bulk gauze, cover with border gauze, change daily and as needed if loose or soiled.” 65. | The May and June 2007 Treatment Administrative Record revealed daily documentation that the nurses had not followed the April 25, 2007 order and instead had treated the coccyx pressure ulcer with an older order dated April 16, 2007 as follows: "Coccyx: Apply Xenaderm, Cover with border gauze daily." 66. An interview with the Unit Manager and Director of Nursing on June 7, 2007 at approximately 5:45 p.m. validated that the nurses had not treated the pressure ulcer according to the newer treatment orders. 67. An observation of resident number two’s (2) coccyx pressure ulcer dressing and treatment change on June 7, 2007 at approximately 6:00 p.m. with the Director of Nursing and Unit Manager revealed that the old dressing had not been dated nor initialed. It also revealed that the nurse removed the old dressing, and there was no fluffed bulk gauze dressing in the wound bed as ordered. Also, the nurse applied the medication Accuzyme into the wound bed with his gloved finger. Additionally, when the nurse removed the old coccyx pressure ulcer dressing, two (2) stage II pressure ulcers were observed beneath the adhesive border of the dressing on the right buttock side. The right buttocks pressure ulcer measured 2 cm. in length by | cm. in width and 1 cm. in length by 1 cm. in width. 68. An interview with the Director of Nursing and Unit Manager validated the above dressing change and treatment as observational findings on June 7, 2007 at approximately 6:15 p.m. 69. A review of a weekly pressure ulcer assessment documentation dated May 31, 2007 revealed that the 2 stage II right buttock pressure ulcers had been identified on May 31, 2007; however, a review of the physician's orders along with the May and June 2007 Treatment Administrative Record revealed that treatment orders had not been obtained nor had any treatments been done for those buttock pressure ulcers. 70. An interview with the Director of Nursing on June 7, 2007 at approximately 6:30 p.m. validated that treatment orders for the right buttock pressure ulcers which had been identified on May 31, 2007 had not been obtained. 71. During a tour of the facility on June 6, 2007 at approximately 10:30 a.m., the Unit Manager indicated that Resident number nine (9) had a stage Il wound on his/her ankle. 72. Areview of the dietician's progress notes dated May 26, 2007 revealed Resident number nine (9) had a wound on the right ankle. There was a recommendation for the resident to continue on multivitamins with minerals daily to promote wound healing. 73. Arecord review revealed there was not a physician's order for multivitamins with minerals for Resident number nine (9). The physician order sheet for the month of June 2007 did not have an order for multivitamins with minerals. The Medication Administration Records for May 2007 and June 2007 did not indicate that this medication had been administered to the resident since May 26, 2007. 74. An interview with the nurse on June 7, 2007 at approximately 10:10 a.m. revealed that a request from the dietician with this recommendation was not available. The nurse said that the process was for the kitchen supervisor to submit a dietician/physician communication with the recommendations to nursing and then nursing will get the physician's order. 75. During a meeting with the Director of Nursing and a nurse on June 7, 2007 at approximately 11:30 a.m., the Director of Nursing said the kitchen supervisor did not have the dietician/physician communication from May 26, 2007 for this resident. The Director of Nursing said that beginning June 2007; she was receiving these dietician/physician communications but did not have the one for Resident number nine (9). 76. On June 6, 2007 at approximately 11:35 a.m., Resident number four (4) was observed outside in the courtyard with a pack of cigarettes and a lighter smoking alone. The resident was observed dropping cigarette butts on the sidewalk. Approximately thirty-five (35) cigarette butts were observed on the mulch in the area where the resident was observed smoking. The resident was observed disposing of cigarette ashes on the electric wheel chair control and ci garette ashes were observed on his/her shirt. 77. The last safe smoking evaluation dated December 2006 indicated that Resident number four (4) was not able to light and smoke a cigarette while demonstrating safe technique for putting out the lighters and disposing of ashes. 78. During an interview on June 6, 2007 at approximately 4:00 p.m., the administrator stated that it was the facility policy that no resident should be outside with a lighter smoking unsupervised. 79. The facility's smoking policy stated that staff members will maintain all smoking materials for residents who smoke and supervise those residents who need assistance. 80. A review of Resident number fourteen’s (14) physician orders revealed an order for a midline IV to be inserted on May 29, 2007. An IV nurse's progress notes dated May 29, 2007 at 10:30 p.m. revealed that the midline had been inserted for the purpose of drawing blood and administering IV fluids. 81. On June 6, 2007 at approximately 3:00 p.m., observation of the IV site revealed that the IV had been discontinued earlier in the day. An interview with the Unit Manager at this time confirmed that the IV line had been ordered discontinued that morning and was pulled. A nurse's note dated June 6, 2007 confirmed this; however, review of the Treatment Administration Record and physician orders for May and June 2007 revealed that orders for IV flushes and IV site dressing changes had not been obtained nor administered. 82. Aninterview with the Unit Manager and Director of Nursing on June 7, 2007 at approximately 10:00 a.m. verified the above findings. 83. | Areview of Resident number ten’s (10) medical record revealed his/her admission date from the hospital to the facility as May 22, 2007. The initial nursing assessment dated May 22, 2007 revealed that he/she had been admitted with a triple lumen IV peripherally inserted central catheter line in the right jugular area. The resident received antibiotics through the IV line as ordered continued from his/her hospitalization. 84. Observation of the right jugular Peripherally Inserted Central Catheter line on June 7, 2007 at 7:45 a.m. with the wound care licensed practical nurse revealed that the IV dressing was not intact. The clear Tegaderm type dressing was rolled up on the bottom and left side. There was gauze surrounding the insertion site which had a small amount of dried reddish-brown residue on it. The dressing was dated June 3, 2007. 85. | A review of the physician orders revealed that the Peripherally Inserted Central Catheter line dressing change orders had not been given at admission. A telephone order dated May 30, 2007, eight (8) days after Resident number ten’s (10) admission revealed the following order: Change IV dressing every week on Sunday and as needed. 86. Continued observation of the Peripherally Inserted Central Catheter line dressing with the Director of Nursing on June 7, 2007 at approximately 6:40 p.m. revealed that the un-intact dressing had not been changed. 87. An interview with the Director of Nursing at the above time stated that it should have been changed immediately after being observed by the nurse in the morning when the dressing had come loose. 88. An interview with the regional nurse at approximately 7:00 p.m. on June 7, 2007 stated that IV Peripherally Inserted Central Catheter lines with gauze dressings under a clear Tegaderm styled dressing should be changed every twenty-four (24) hours when soiled. 89. | The Agency determined that this deficient practice will result in no more than minimal physical, mental, or psychosocial discomfort to the resident or has the potential to compromise the resident’s ability to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. The Agency cited the Respondent for a class III deficiency as set forth in Section 400.23(8)(c), Florida Statutes (2006). 90. Acclass III deficiency is subject to a civil penalty of $1,000 for an isolated deficiency, $2,000 for a patterned deficiency, and $3,000 for a widespread deficiency. 91. Based upon the above findings, the Respondent’s actions, inactions or conduct constituted an uncorrected class III deficiency pursuant to section 400.23(8)(c), Florida Statutes (2006). 92. The Agency provided Respondent with a mandatory correction date for this deficient practice of June 29, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of ONE THOUSAND DOLLARS ($1,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Sections 400.23(8)(c) and 400.102, Florida Statutes (2006). COUNT I Assignment Of Conditional Licensure Status Pursuant To Section 400.23(7)(b), Florida Statutes (2006) 93. | The Agency re-alleges and incorporates by reference the allegations in Count I and Count II. 94, The Agency is authorized to assign a conditional license status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2006). 95, Due to the presence of two class III deficiencies that were not corrected within the time established by the Agency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes (2006), and the rules adopted by the Agency. 96. The Agency assigned the Respondent conditional licensure status with an action effective date of June 7, 2007. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. 97. The Agency assigned the Respondent standard licensure status with an action effective date of June 28, 2007. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the Respondent conditional licensure status for the period between the assignment of the conditional license and the standard license pursuant to Section 400.23(7)(b), Florida Statutes (2006). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency on Count I, Count TI, and Count IIL. 2, Impose an administrative fine against the Respondent in the amount of TWO THOUSAND DOLLARS ($2,000.00). 3. Assign a conditional license to the Respondent for the period of June 7, 2007, to June 28, 2007. 4. Assess costs related to the investigation and prosecution of this case. 5. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this 34 day of August, 2007. fos paaliss ace Senior Attorney Florida Bar No. 0355712 Agency for Health Care Administration 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3209 NOTICE 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; TELEPHONE (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT A REQUEST FOR HEARING MUST BE RECEIVED WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. 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: 7006 2760 0003 7781 4868 on August Blab, 2007 to: Patrice Evans, Administrator, Sovereign Healthcare of Metro West, LLC d/b/a Metro West Nursing and Rehab Center, 5900 Westgate Drive, Orlando, Florida 32835 and by U.S. Certified Mail, Return Receipt No: 7006 2150 0004 5870 9372 to National Corporate Research, LTD., Inc., Registered Agent, 515 East Park Avenue, Tallahassee, Florida 32301. Copies furnished to: 4 fall foobs, Senior Attorney Florida Bar No. 0355712 Agency for Health Care Administration 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3209 Patrice Evans, Administrator Sovereign Healthcare of Metro West, LLC d/b/a Metro West Nursing and Rehab Center 5900 Westgate Drive Orlando, Florida 32825 (U.S. Certified Mail) Joel Libby Field Office Manager Agency for Health Care Administration Hurston South Tower oo National Corporate Research, LTD., Inc. Registered Agent 515 East Park Avenue Tallahassee, Florida 32301 (U.S. Certified Mail) Mary Daley Jacobs Senior Attorney Agency for Health Care Administration 2295 Victoria Avenue, Room 346C 400 West Robinson Street, Suite S309 Fort Myers, Florida 33901 Orlando, Florida 32801 (interoffice Mail) (Interoffice Mail) 20 Exhibit A Original Certificate of Conditional License For Sovereign Healthcare of Metro West, LLC d/b/a Metro West Nursing and Rehab Center Certificate No. 14556 License No. SNF16240961

Docket for Case No: 07-004480