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
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STATE OF FLORIDA Pa {}
AGENCY FOR HEALTH CARE ADMINISTRATION
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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
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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:
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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.
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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.
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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
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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
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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.
|