STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION / °6P 27 OMe , Abn SIOM fie eft OF STATE OF FLORIDA, . O “f- a i «s . HEAR RAT Ve AGENCY FOR HEALTH CARE &s ADMINISTRATION, Petitioner, vs. , Case Nos. 2007007931 (Fine) 2007007932 (Cond. ) THE HEALTH CENTER OF HUDSON, INC., (THE), d/b/a BAYONET POINT HEALTH & 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 HEALTH CENTER OF HUDSON, INC., (THE), d/b/a BAYONET POINT HEALTH & REHABILITATION CENTER, (hereinafter “Respondent”), pursuant to §$120.569 and 120.57 Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from.Standard-to~Conditionalcommencing May” 31,2007; "and ending June 4, 2007, and impose an administrative fine in the amount of $2,500.00, based upon Respondent being cited for one State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60, 400.062, and 408.802(3), Florida Statutes (2007). 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, and Chapter 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 180-bed nursing home, located at 7210 Beacon Woods Drive, Hudson, FL 34667, and is licensed as a skilled nursing facility license number 1362096. 5. Respondent was at all times material to the allegations of this complain, 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 in this count. 7. Section 400.102(1) (a), Fla. Stat. (2007), provides: “(1) Any of the following conditions shall be grounds for action by the agency against a licensee: - (a) An intentional or negligent act materially affecting the health or safety of residents of the facility; .. .” ) 7.1. Respondent Facility has a duty toward its residents under the statutory definition of “practice of professional nursing,” under the standard of care set forth by the minimum level of care and services to be provided to residents pursuant to Chapter 400, Part II, Florida Statutes, and implementing rules, under the common law that actions undertaken for the benefit of another must be performed with reasonable care, under Respondent Facility’s own policies and procedures regarding patient care and services, and under the Resident’s Statement of Right which includes the right to receive adequate and appropriate health care and protective and support services. 7.2. Respondent Facility breached its duty to Resident #1 when its nurse failed to follow facility policy, when Respondent Facility failed ensure that Resident #1’s vital signs were taken and when Respondent Facility failed’ to ensure that Resident #1’s physician was notified about the change in Resident #1’s condition. 7.3. Respondent Facility’s breach of its duties to Resident #1 has compromised Resident #1’s ability to maintain or -reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. 8. Section 464.003(3), Florida Statutes (2007), defines: (3) (a) "Practice of professional nursing" means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to _ Prescribe such medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. (b) "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 of a 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 édiicational preparation and. experience in nursing. 9. 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.. Any violation of these rights will constitute grounds for action by the Agency under § 400.102, Florida Statutes (2007). § 400.022, Florida Statutes (2007). 10. On or about May 31, 2007, the Agency conducted two Complaint Surveys (CCR#2007005750 & #2007005789) at Respondent’s facility. 11. Based on interview and record review, the facility failed to meet the needs of and prevent the neglect of one (Resident #1) of five sampled residents by not performing vital signs when the resident complained of nausea/vomiting and neck/shoulder and left-arm-pain.-These~actions resulted” in findings of Immediate Jeopardy. 12. Resident #1 was admitted to the "A Wing" of the facility with diagnoses that include Dementia, Diabetes, Glaucoma, Hypertension, Duodenitis with Hemorrhage, Anemia, Weakness, Nausea, Vomiting, and Esophageal Reflux. During Resident #1's time on the "A Wing," vital signs are documented as being taken at least twice daily, with most days taken every shift. 13. On May 7, 2007, Resident #1 was transferred to the "B Wing" of the facility. Since May 1, 2007, the "Vital Signs Record" form shows vitals taken twice on May 1 and May 2, three times on May 3 and May 4, twice on May 5, three times on May 6, once on May 7, and twice on May 8. The clinical record does not indicate routine vital signs were taken on May 9, 2007, nor when the family member informed the nursing staff of the family member’s concern for the resident due to the resident's complaints of nausea/vomiting, neck/shoulder and left arm pain. The .clinical record also does not indicate that an assessment of the neck/should and left arm pain was done in order to determine if the pain were arthritic or radiating; that later would have indicated a change in condition, perhaps a heart condition. 14. %In an interview conducted with the Respondent Facility’s Director of Nursing on May 31, 2007, at approximately 2:30 p.m., the Director of Nursing indicated it was felt that the Resident #1.1s nausea/vomiting was--a-result.of-a-"gastrointestinal- bug" that had been going through the facility and the left arm pain was due to "arthritis." The Director of Nursing was unable to find any vital signs in the clinical record for Resident #1 for May 9, 2007. 15. The facility Risk Manager indicated in a conversation at approximately 2:00 p.m. on May 31, 2007, that an adverse incident was not conducted because Resident #1 "died of cardiac arrest.” 16. The facility acknowledged the the nurse did not follow facility practice as evidenced by providing a copy of a "Notice of Disciplinary Action" dated May 11, 2007 and submitted against an LPN (Licensed Practical Nurse) on duty during the 3:00 p.m. to 11:00 p.m. shift on May 9, 2007, which states: Type of Disciplinary Action: Final Written Warning Documented Supervisor's Statement: Failure to follow facility policy regarding {implement of treatments (unable to read)} proper documentation and not reporting change of status in a timely manner to charge nurse to assure timely follow-up -- any further non-compliance will lead up to and/or include suspension and/or termination. 17. A hand-written note on the bottom of the form states, "FRM, DON, BW, UM met with (name of LPN) 10:00 a.m. on 05/16/07." The document is signed by the LPN on May 16, 2007. No documentation was provided by the facility to indicate that the nurse received inservices training after the disciplinary action. 18. A phone interview was conducted with the resident's physician, who is also the Medical Director of the facility, at 11:05 a.m. on June i, 2007, who indicated he knew the resident for 20 years and had just had a conversation with the resident either the day of the incident or day before in the facility while the resident was ambulating down the hall in a walker. The physician stated the resident asked him when the resident could go home. The physician. stated the pain in the resident's left arm has been "on going" and facility staff did "not perceive (the pain to be) a change in his/her overall condition. The resident was elderly with multi-system problems." The physician did go on to. state that facility staff "probably should have done vital signs.” 19. Respondent Facility has a duty toward its residents under the statutory definition of “practice of professional nursing,” under the standard of care set forth by the minimum level of care and services to be provided to residents pursuant to Chapter 400, Part II, Florida Statutes, and implementing rules, under the common law that actions undertaken for the benefit of another must be performed with reasonable care, under Respondent Facility’s own policies and procedures regarding patient care and services, and under the Respondent’s Resident’s Statement of Right which includes the right to receive adequate and appropriate.-health-care-and-protective~and~support™services: 20. Respondent Facility breached its duty to Resident #1 when its nurse failed to follow facility policy --. when its nurses failed to assess, evaluate and intervene as to Resident #1‘s complaint of shoulder pain and nausea -- when Respondent Facility failed ensure that Resident #1’s vital signs were taken -- and when Respondent Facility failed to ensure that Resident #1’ 5s physician was notified about the change in Resident #1’s condition. 21. This action or inaction of the Respondent caused the care provided to resident #1 to be inadequate and is in violation of Florida law. . 22, The Agency determined Respondent had not provided the necessary care and services and had compromised the resident's ability to maintain or reach his or her highest practicable physical, mental and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care and provision of services and cited this deficient practice as an Isolated State Class II deficiency. 23. The Agency provided Respondent with the mandatory correction date for this deficient practice of June 30, 2007. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400..23.(8).(a).,..400.121..and..400..102,...Florida..Statutes..(2007)- COUNT IT “24. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and seven (7) through twenty-three (23) as if fully set forth in this count. 25. Based upon Respondent’s one cited State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7) (b), Florida Statutes (2007). 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 (2005) commencing May 31, 2007, and ending June 4, 2007. Respectfully submitted this uy aay of September, 2007. es H. Harris, Esq. ‘RJa. Bar. No. 817775 Assistant General Counsel Agency for Health Care Administration 525 Mirror Lake Drive, 330H St. Petersburg, FL 33701 727-552-1435 DISPLAY OF LICENSE Pursuant to § 400.23(7) (e), Fla. Stat. (2005), 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. 10 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: 7007 0710 0004 0429 1488 to: David W. Cross, Administrator, Bayonet Point Health & Rehab, 7210 Beacon Woods Dr., Hudson, FL 34667 and by U.S. Certified Mail, Return Receipt No.: 7007 0710 0004 0429 1792 to Corporation Service Company, Reg. Agent., 1201 Hays Street, Tallahassee, FL 32301-2525, on September vad 2007. Copies furnished to: David W. Cross, Administrator Corporation Service Company Bayonet Point Health & Rehab Registered Agent for 7210 Beacon Woods Dr. The Health Center of Hudson, Inc. Hudson, FL 34667 1201 Hays Street (U.S. Certified Mail) Tallahassee, Florida 32301-2525 (U.S. Certified Mail) Patricia-R:-Caufman - James-H: Harris, Esq: Field Office Manager Agency for Health Care Admin. 525 Mirror Lake Drive, 4" Floor 525 Mirror Lake Drive, 330H St. Petersburg, Florida 33701 St. Petersburg, Florida 33701 Unteroffice) | nteroffice) 11

Docket for Case No: 07-004483