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AGENCY FOR HEALTH CARE ADMINISTRATION vs QUALITY CONSULTING, LLC, D/B/A CROSS POINTE CARE CENTER, 07-004576 (2007)

Court: Division of Administrative Hearings, Florida Number: 07-004576 Visitors: 2
Petitioner: AGENCY FOR HEALTH CARE ADMINISTRATION
Respondent: QUALITY CONSULTING, LLC, D/B/A CROSS POINTE CARE CENTER
Judges: ERROL H. POWELL
Agency: Agency for Health Care Administration
Locations: Lauderdale Lakes, Florida
Filed: Oct. 04, 2007
Status: Closed
Settled and/or Dismissed prior to entry of RO/FO on Friday, February 22, 2008.

Latest Update: Dec. 22, 2024
itv é™ fs : f 9 ‘S&p STATE OF FLORIDA Pa {} AGENCY FOR HEALTH CARE ADMINISTRATION A : Opis, 4e4 STATE OF FLORIDA, AGENCY FOR Ol -U5 (y OS PY Ope HEALTH CARE ADMINISTRATION, WNT ye Petitioner, AHCA No.: 2007006851 AHCA No.: 2007006852 v. ‘Return Receipt Requested: 7002 2410 0001 4232 2453 QUALITY CONSULTING, LLC d/b/a 7002 2410 0001 4232 2460 CROSS POINTE CARE CENTER, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the State of Florida, Agency for Health Care Administration (hereinafter “AHCA”), by and through the undersigned counsel, and files this administrative complaint against Quality Consulting, LLC d/b/a Cross Pointe Care Center (hereinafter “Cross Pointe Care Center”) pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2005) hereinafter alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine in the amount of $10,000.00 pursuant to Sections 400.23(8) (b), Florida Statutes [AHCA No.: 2007006851]. 2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7) (b), Florida Statutes [AHCA No. 2007006852]. 3. This is an action to impose a 6-month survey cycle fee of $6,000.00. Cross Pointe Care Center qualifies for a 6-month survey cycle fee for being cited for a Class I deficiency pursuant to Section 400.19, Florida Statutes. JURISDICTION AND VENUE 4. This court has jurisdiction pursuant to Section 120.569 and 120.57, Florida Statutes and Chapter 28-106, Florida Administrative Code. | 5. Venue lies in Palm Beach County pursuant to Section 120.57, Florida Statutes (2006), and Rule 28-106.207, Florida Administrative Code (2006). PARTIES 6. AHCA is the enforcing authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes and Rule 59A-4, Florida Administrative Code. 7. Cross Pointe Care Center operates an 88-bed skilled nursing facility located at 440 Phippen-Waiters Road, Dania Beach, Florida 33004. Cross Pointe Care Center is licensed as a skilled nursing facility license number 1119096. Cross Pointe Care Center was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I CROSS POINTE CARE CENTER FAILED TO PROVIDE ADEQUATE SUPERVISION FOR COGNITIVELY IMPAIRED RESIDENTS WITH KNOWN ELOPEMENT RISK. SECTION 400.102(1) (a), FLORIDA STATUTES (QUALITY OF LIFE) CLASS I 8. AHCA re-alleges and incorporates (1) through (7) as if > fully set forth herein. 9. A complaint investigation survey was conducted on May 11, .2007 with a partial extended survey conducted on May 18, 2007. Immediate Jeopardy was identified.. Based on record reviews, interviews, and observations, it was determined that the facility failed to provide adequate supervision for cognitively impaired residents with known elopement risk, for 1 of 5 sampled residents (Resident #2). The findings include the following. 10. Resident #2 was admitted to the facility on 09/15/05, with diagnosis of High Blood Pressure, Dementia, Multiple Sclerosis, Weakness and History of Seizures. 11. A review of the murses’ notes dated 04/15/06 documented "resident alert and oriented to name only. Wandering around and continually trying to open all exit doors. "On 06/08/06, the record documented "continually pacing . throughout the facility." 12. On 06/10/06, as documented by nurses’ notes, at 10:05 PM, resident #2 was "found on Stirling Road and brought back by a neighbor. Alert, oriented to name, no apparent injury noted." The record failed to contain documentation that an investigation of this elopement was conducted. 13. The clinical record noted elopement attempts on the following dates: a. 09/27/06 at 1 PM, "Resident OOB (Out of bed) ‘continuously pacing back & forth to exit trying to get home to Miami. Redirected several times." b. 09/27/06 at 8 PM, Pacing in the facility asking for exit door. c. 11/24/06 at 1 PM continues to pace hallways always checking exit doors. 14. A Social Services’ progress note, dated 09/26/06, documented the resident continued to ambulate throughout facility. On 12/26/06, Social Services notes documented "Resident still seems to want to elope and continues to follow ( \ ( \ visitors to the door. She is still being monitored to reduce potential for elopement." 15. The current Minimum Data Set (MDS) dated 03/26/07, documents the resident is moderately impaired for decision, with poor decision making skills and required supervision. Resident #2 ambulates independently. . 16. On 5/11/07, a review of the care plan for resident #2, dated 10/4/05 and last reviewed 3/26/07, documented the problem as 'Risk for Elopement', exit seeking, diagnosis of dementia, and Agenda behavior is home. 17. The goals of the plan of care included: "Reduce episodes of attempts at elopement by 50%". . 18. Interventions included: Review risk factors, has history of elopement. Attempt’ to meet needs prior to attempt to elope. Pictures posted. Provide diversionary activity to deal with agenda behavior. Observe and monitor frequently throughout shift. Encourage participation in small group activities. Elopement precaution. 19. An intervention for a wanderguard bracelet had been crossed out. The care plan did not specify how the resident would be monitored and by whom to prevent elopement. 20. A review of the nurses’ progress notes, dated 05/05/07, revealed the following: OO) CO) a. “on. 05/05/07, at 10:30 AM, a Certified Nursing Assistant (CNA) notified the charge nurse resident #2 was missing from the facility. A search of the ‘building was initiated. The Resident was not found. b. At 9:00 AM, the resident was observed ambulating in hallway. No sign of distress noted. c. At 9:30 AM, the resident was observed by the CNA pushing another resident in wheel chair by room #10. d. At 10:00 AM, resident. was observed sitting in room #1 by bed C. (Room #1 is located on the West Wing and is another resident's room, close to a fire exit that leads to street.) e. At 11:00 AM, Director of Nurses (DON): . was notified. E. At 11:10 AM, 911 was notified. g. At 11:20 AM, law enforcement responded and initiated search. h. At 12:30 PM, the resident's son notified. i. Search continued by law enforcement. j. At 3:10 PM, Broward County Sheriff's Office (BSO) Sergeant requested and obtained a copy of the medical record. k. At 6:00 PM, an Officer from BSO came to inquire if the resident had been located. mt os 21. The 05/06/07 nurses’ notes documented the facility received a telephone call from a BSO deputy stating the resident was found and requested that. a staff member come to the site. Two staff members went to the scene, the RN supervisor and a LPN. Upon arrival at the scene, the nurses identified the resident, who was found deceased in a white vehicle. 22. Interviews were conducted on 05/11/07, at approximately 11:00 AM, with the DON and Administrator. Both staff stated they did not know how resident #2 had gotten out of the facility. The Administrator stated he believed the resident had -not eloped in over a year. A later interview with ‘the Administrator, at approximately 3:00 PM, revealed the resident had ‘eloped from the facility on 06/10/06, less than one year ago... 23. Interviews with alert and oriented residents indicated "everybody knew resident #2 was bent on getting out. That she would try to get out all the time. She would try to get out the front but would get caught by someone up front." 24. At the time of the 05/11/07 investigation, the facility only provided a "A missing resident plan" for review, the facility staff did not provide a policy in regard to prevention of elopement. On 05/18/07 at 3:20 PM, a policy titled "Elopement policy for prevention of at risk residents" was provided by the administrator. > C) 25. Upon entry into the facility lobby on 05/18/07 at 9:35 AM, the main entrance leading directly into the facility was observed to be locked. Entry to the facility is accessed by touching a release button at the double doors. Another release was observed at the receptionist desk. An interview with the receptionist on 5/18/07 at 9:35 AM revealed her hours to be 8:30 . AM to 5PM Monday through Friday. The receptionist stated she was not aware if someone is at the front lobby during the weekends. 26.. On 5/18/07, interviews were conducted with personnel identified to have been on duty on the East Wing, which is the Wing.in which the resident resides. Interview with the facility staff revealed the staff did not know how the resident exited the facility. 27. During an interview on 5/18/07 at 11:05 AM with a Licensed Practical Nurse (LPN), revealed she reported to duty on 5/5/07 at 7 AM, and worked until 3 PM. On arrival to the East Wing on 5/5/07 the nurse stated she made rounds and checked the dining room where the resident was observed waiting for breakfast. The nurse also stated between 10:10 AM and 10:15 AM the resident was observed pacing the hallway going towards the West Wing. 32. Interview with a supervisor reflected there is no receptionist or other personnel at the front entrance on the weekends. The supervisor was not aware if any family members had C). , C) the code for the front entrance door leading directly into the facility, however, she indicated that some alert and oriented residents had the code to exit the facility by the front entrance on 5/5/07. 33... At 12:25 PM on 05/18/07, an’ interview was conducted with the Certified Nursing Assistant who was assigned to the resident on 5/5/07. During this interview, the nursing assistant stated on 5/5/07, while providing | care to the resident's roommate in room #30, resident #2 left the room at about 10:05 AM., and wandered towards the West Wing of the facility. After completing the care on the resident's roommate in room #30 the CNA ‘went to find Resident #2 on the West wing. The CNA reported "if someone was walking out the font door, resident #2 would try to walk behind." 34. At 2:02 PM on 5/18/07 during an interview with the LPN who documented the hourly observations of resident #2 on 5/5/07, it was revealed resident (#2) was last observed at 10 AM walking towards the west wing. The nurse stated the resident did not try to elope out of the hallways exit doors, but the resident would always knock on the front entrance door to get out. The nurse was aware the resident had eloped before, less than a year ago. 35. The facility's six (6) exits were observed on 5/18/07 between 1:05 and 1:30 PM. The Administrator, present at the time of this observation, activated the alarm system located on the 9 a — two exit doors of the West wing. The alarm on the exit door near the nursing station was not audible in Room #1 and the alarm on the exit door at the end of the hallway, near Room #1, was not heard in Room #15 and #16. Two staff who were present on the west wing and the administrator verified the audible alarms were not loud enough to alert the staff when the staff are away from the nurses station or in a resident's room. The exit doors of the West wing open directly to a parking area adjacent to the street. 36. The exit door located at the end of the East wing opens to a fenced area with a gate. Interview with the Administrator during the observation on 5/18/07 revealed this gate was unsecured on 5/5/07. 37. Based on the foregoing facts, Cross Pointe Care Center violated Section 400.102 (1) (a), Florida Statutes, herein Classified as an isolated Class I violation pursuant to Section 400.23(8), Florida Statutes, which carries, in this case, an assessed fine of $10,000.00. This also gives rise to conditional licensure status pursuant to Section. 400.23(7) (b), Florida Statutes. SURVEY FEE Pursuant to Section 400.19, Florida Statutes (2006), AHCA may impose a 6-month survey cycle fee of $6,000.00. Cross Pointe Care Center qualifies for a 6-month survey cycle fee for being 10 cited for a Class I deficiency pursuant to Section 400.19, Florida Statutes. A 6-month survey cycle fee of $6,000.00 -has been assessed in this case. . DISPLAY OF LICENSE Pursuant to Section 400.25(7), Florida Statutes Cross Pointe Care Center shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility. The conditional License is attached hereto as Exhibit “aA” 11 EXHIBIT “A” Conditional License License # SNF 1119096; Certificate No.: Effective date: 05/18/2007 Expiration date: 12/30/2007 Standard License License # SNF 1119096; Certificate No.: Effective date: 06/08/2007 Expiration date: 12/30/2007 12 14586 14589 PRAYER FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: 1. Make factual and legal findings in favor of the Agency on Count I. 2. Assess against Cross Pointe Care Center an administrative fine of $10,000.00 for the violation cited above. 3. Assess against Cross Pointe Care Center a conditional license in accordance with Section 400.23(7), Florida Statutes. 4, Assess a 6-month survey cycle fee of $6,000.00 against Cross, Pointe Care Center pursuant to Section 400.19, Florida Statutes. 5. Assess costs related to the investigation and prosecution of this matter, if applicable. 6. Grant such other relief as the court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2005). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration and delivered to the Agency Clerk, Agency for 13 C) CO) Health Care Administration, 2727 Maban Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECHIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER ‘ Alba M. i. ha nade ra} Fla. Bar No.: 0880175 Assistant General Counsel Agency for Health Care Administration 8350 N.W. 52 Terrace - #103 Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Blvd. - Suite 500 Delray Beach, Florida 33484 (U.S. Mail) Long Term Care Program Office Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) 14 O O Karen Davis Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida’ 32308 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Steve Valentine, Administrator, Cross Pointe Care Center, 440 Phippen-Waiters Road, Dania Beach, Florida 33004; K. C. Cross, Registered Agent, 4 West Dania Beach Blvd., Dania, Florida 33004 on this aQistaay of August, 2007. Alba M. 19.6 se ‘i 15

Docket for Case No: 07-004576
Issue Date Proceedings
Jun. 08, 2009 (Agency) Final Order filed.
Jun. 08, 2009 Settlment Agreement filed.
Feb. 22, 2008 Order Closing File. CASE CLOSED.
Feb. 20, 2008 Motion to Close File and Relinquish Jurisdiction filed.
Feb. 14, 2008 Amended Notice of Taking Deposition Duces Tecum filed.
Feb. 12, 2008 Notice of Taking Deposition Duces Tecum filed.
Jan. 30, 2008 Petitioner`s Notice of Service of its First Request for Admissions, Interrogatories, and Production of Documents to Respondent Cross Pointe Care Center filed.
Jan. 28, 2008 Petitioner`s Notice of Service of it`s First Request for Admissions, Interrogatories, and Production of Documents to Tenet St. Mary`s Medical Center filed.
Jan. 04, 2008 Order Granting Continuance and Re-scheduling Hearing by Video Teleconference (hearing set for March 13 and 14, 2008; 9:00 a.m.; Lauderdale Lakes and Tallahassee, FL).
Jan. 03, 2008 Motion for Continuance filed.
Jan. 02, 2008 Response to Request for Production filed.
Nov. 15, 2007 Notice of Unavailability filed.
Nov. 13, 2007 Request for Production filed.
Nov. 09, 2007 Respondent`s First Set of Interrogatories filed.
Oct. 16, 2007 Order of Pre-hearing Instructions.
Oct. 16, 2007 Notice of Hearing (hearing set for February 12 and 13, 2008; 9:00 a.m.; Fort Lauderdale, FL).
Oct. 12, 2007 Joint Response to Initial Order filed.
Oct. 04, 2007 Initial Order.
Oct. 03, 2007 Standard License filed.
Oct. 03, 2007 Conditional License filed.
Oct. 03, 2007 Administrative Complaint filed.
Oct. 03, 2007 Answer to the Administrative Complaint and Request for Hearing filed.
Oct. 03, 2007 Order of Dismissal without Prejudice Pursuant to Section 120.569(2)(c), Florida Statutes, to Allow for Amendment and Resubmission of Petition filed.
Oct. 03, 2007 Amended Answer to the Administrative Complaint and Request for Hearing filed.
Oct. 03, 2007 Notice (of Agency referral) filed.
Source:  Florida - Division of Administrative Hearings

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