STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION AGENCY FOR HEALTH CARE O( . SUq8 ADMINISTRATION, Petitioner, AHCA No.: 2007010580 AHCA No.: 2007010582 Vv. : Return Receipt Requested: 7004 2890 0000 5526 0989 QUALITY TOTAL CARE, LLC d/b/a 7004 2890 0000 5526 0996 THE CROSSINGS, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Quality Total Care, LLC, d/b/a The Crossings (hereinafter “The Crossings"), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2007), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $12,500.00 pursuant to Section 400.23(8), Florida Statutes (2007), for the protection of the public health, safety and welfare, and $6,000.00 survey fee pursuant to Section 400.19(3), Florida Statutes (2007). 2. This is an action to impose a Conditional Licensure status to The Crossings, pursuant to Section 400.23(7) (b), Florida Statutes (2007). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and Chapter 28- 106, Florida Administrative Code. 4. Venue lies in Palm Beach County, pursuant to Section 400.121(1)(e), Florida Statutes (2007), and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing homes, pursuant to Chapter 400, Part II, Florida Statutes, (2007), and Chapter 59A-4 Florida Administrative Code. 6. The Crossings is a 60-bed skilled nursing facility located at 4445 Pine Forest Drive, Lake Worth, Florida 33463. The Crossings is licensed as a skilled nursing facility; Conditional license number’ §N1219096; certificate number 14710, effective 08/16/2007. The Crossings 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 THE CROSSINGS FAILED TO PROVIDE ADEQUATE SUPERVISION AND A SAFE, SECURE ENVIRONMENT, RESULTING IN TWO ELOPEMENTS IN TWO MONTHS Section 400.102(1) (a), Florida Statutes (HEALTH AND SAFETY OF RESIDENTS) PATTERN CLASS I DEFICIENCY 7. AHCA re-alleges and incorporates paragraphs (1) through (7) as if fully set forth herein. 8. During a complaint investigation conducted on 8/16/07 and based on observations, record review, and interviews, the facility failed to ensure that 2 of 8 sampled residents (#1 and #2) were receiving adequate supervision, which resulted in two elopements in two months. Both residents were found by the police and returned to the facility. The facility failed to adequately assess for risk of elopement and implement adequate care interventions. The facility also failed to maintain a safe environment to ensure the safety and security of residents by failing to monitor door alarms and surveillance camera monitors. The Crossings actions and/or omissions created a situation, which, has, or is likely to cause serious injury, harm, impairment, or even death. 9. A review of the Clinical Record of Resident #1 revealed that the resident was originally admitted to the facility on 4/18/07. The Minimum Data Set (MDS) dated 5/6/07 reveals the admission diagnosis of hypertension, depression, dementia other than Alzheimer and anemia. The MDS also reveals that Resident #1 had a Cognitive Status of 2, modified independence and short term memory problems. Section E4 of the same MDS reveals that the resident was rated as wandering 3 on a daily basis and this behavior was not easily altered. Section G of the MDS reveals that the resident was rated as being able to walk between locations in his/her room, in the corridors and on/off the unit, as requiring oversight, encouragement or cueing 3 or more times, during 7 days, or supervision 3 or more times plus physical assistance provided 1 or 2 times during the last 7 days. 10. The Elopement Evaluation Screen form dated 5/27/07 for Resident # 1 reveals: * The resident was ambulatory * The resident had a habit of wandering * The resident has a habit of pacing. * The resident used verbal/nonverbal comments/ behaviors such as "I'm going home" or pushing on doors. * The resident had a history of Alzheimer's, dementia or other psychiatric history. * The resident had eloped before. * The family has commented that resident has had wandering tendencies. 11. The Elopement Evaluation Screen scoring reveals that a score of 5 or higher is a Wanderer/High Risk potential. The score documented for Resident #1 was a seven (7). The form consists of a total of 9 questions, which must be answered as either a "yes" or a "no". A notation at the bottom of the Elopement Evaluation Screening reveals an instruction to complete a new assessment and give a copy to the Director of Nursing if the resident attempts an elopement. The 5/27/07 Elopement Evaluation Screening was the only screening in the Clinical Record for Resident #1 on 8/16/07 at 8:35 AM. 12. A Care Plan dated 5/27/07 for Resident #1 for Blopement reveals the problem as follows: "At risk for elopement due to agenda behavior, seeking to go _ home, searching for familiar faces, etc." The goal was documented as: "reduce episodes of attempt at elopement by 50 %." The following approaches/interventions were listed: * Review risk factors and history of elopement * Attempt to meet needs prior to attempt to elope * Obtain order for Wander-guard Bracelet * Check battery every shift and as needed * Provide diversionary activity to deal with agenda behavior * Observe and monitor resident frequently throughout shift. 13. A Care plan dated 7/3/07 for Resident #1 for Elopement revealed the identical interventions as those listed on the 5/27/07 Care Plan for Elopement. 14. A nurse's note, dated 6/9/07 at 10 PM, noted the resident was restless, agitated, and wanting to go home. 15. Nurse Notes for Resident #1 the following morning, at 6/10/07 at 10:45 AM, indicates "Pt seen by family member and nursing going into building stating it was too hot outside. Resident removed sweater and was asked to wait so AM meds could be given, after meds pulled Resident was not found, staff nurse was notified." 16. A subsequent entry for Resident #1 dated at 11:00 AM reveals, "Full search was put into effect. All staff was searching for patient, ALF, rehab/bathrooms, bedrooms, patient was not found." 17. A Nurse’s Note at 11:30 AM reveals, "Going to call 911 when Nurse received call from Sheriff's Department. Pt had been located at the Country Inn, 4480 Military Trail; Sheriff stated ambulance would check him/her out and escort him/her back to facility.” 18. The next entry at 11:45 AM reveals, "Received second call from Sheriff Department. Stated they need the Charge Nurse to come to the patient, Staff Nurse went to the Country Inn." 19. The following 12:00 PM entry reveals, "Sheriff's Office stated with second call that the patient was going to be transported to the local hospital’s Emergency Room for evaluation to R/O (rule out) injuries.” 20. A 12:05 PM entry reveals, "Message left for Director of Nursing. Call facility to inform her, Dr. A-- was also called and message left for return call to notify him." 21. A 12:10 PM entry reveals, "Call placed to patient's spouse, to inform him/her of incident, message left for return call." 22. A 12:10 PM entry reveals, "Return call received from Dr. A--, who was notified of the situation and patient being taken to the local hospital." 23. "Late Entry" notation reveals that when the patient was first noticed missing, a staff nurse instructed two Certified Nursing Assistants to observe the main road in search of the patient. The CNA’s saw the patient, but 911 had already arrived. The Certified Nursing Assistants immediately returned to the facility to notify the nurses." 24. A 12:40 PM entry reveals, "Received return call from patient's wife. Notified of incident, spouse was very rude and not understanding." 25. An entry timed 3:00 PM reveals, "Hospital called; patient ready to be transported back to the facility; transport being arranged." 26. An entry dated 5:30 PM reveals, "Resident was returned to the facility, alert, confused and disoriented. Resident was seen in ER of hospital and diagnosed with Urinary Tract Infection. He was given a prescription for Levaquin." 27. On 8/16/07 at 11:43 AM, the Administrator/Owner handed the Surveyor the Elopement Evaluation Screening for Resident #1, dated 7/22/07. .A review of this form reveals that the resident's score for Elopement Risk was not tabulated at the bottom of the page. Eight of the nine questions on the form were answered as, "no", including the question "Has resident ever eloped before?" The only question that had a "ves" answer was that the resident had a history of Alzheimer's, dementia or a Psychiatric history. 28. On 8/16/07 the surveyor interviewed the DON at approximately 11:46 AM and asked if any interventions had been initiated to reduce the risk of Resident #1 eloping again from the facility. The DON confirmed that no additional interventions had been initiated after the 6/10/07 elopement. The DON also confirmed that the facility does not use the Wander-guard bracelet as documented on the Resident's care plan. The surveyor asked the DON to review the Elopement Evaluation Screening, dated 7/22/07 for Resident #1. The DON reviewed the document and was questioned as to why the resident was assessed as no longer being at risk for elopement. The DON stated that she could not explain how this occurred. The DON was asked how Resident #1 was able to elope on 6/10/07. The DON stated that she did not know how the resident exited the building. The DON confirmed that the elopement of Resident #1 had not been fully investigated. 29. At 12:20 PM, the surveyor showed the Elopement Care Plan for Resident #1 to the MDS Coordinator and asked how the facility monitors residents who are at risk for elopement. The MDS coordinator confirmed that the facility does not use the Wander-guard bracelet system. The MDS Coordinator stated — that the "CNAs watch the residents in the hall, that is their job." 30. At 2:50 PM, the surveyor reviewed the Clinical Record for Resident #1 and located a third Elopement Evaluation Screening dated 8/6/07 (the resident was readmitted to the facility on 8/6/07). This form scored Resident #1 as having no risk for elopement (zero). The evaluation also indicated the resident had no history of Alzheimer's or dementia. 31. A review of the clinical record of Resident #2 revealed that the resident was admitted to the facility on 8/6/07. The facility's Social Progress notes dated 8/6/07 indicated the following: a diagnosis of dementia, alert and oriented times two, has confusion; resident has the potential to elope and wander; she walks about the skilled nursing facility since admitted; she enjoys and sits outside on patio. 32. The facility's Elopement Evaluation Screening, dated 8/6/07 reveals: The resident is ambulatory. The resident has a habit of wandering. The resident has a habit of pacing. The resident has a history of Alzheimer's, dementia, or a psychiatric history. * * * * 33. A nurse's note dated 8/9/07 on the 11-7 shift stated the resident attempted to escape. 34. A nurse's note dated 8/10/07 stated that the resident left the property unaccompanied today and was returned to the facility by police, found wandering on street, she was given water to drink and will be monitored while she walks. 35. A nurse's Note dated 98/11/07 stated that the resident was restless asking to go outside to look for her dog, cries when she thinks her dog is lost. 36. A note on 8/12/07 indicates that the patient tries to get out the doors. 37. On 8/14/07, 3-11 shift, resident reports looking for lost poodle. 38. On 8/15/07, note stated resident attempted to exit thru doors after supper. 39. A care plan dated 8/13/07 for Resident #2 to address elopement risk revealed that the facility would: * Observe the resident's location at least every hour with visual checks. * Attempt to determine the cause of wandering. * Code alert bracelet to implement’ security measures for patterns of leaving the unit or going outdoors. * Redirect resident back to his/her room when the code alert alarm has sounded. 40. One of the causes of her wandering seemed to be her need to find her dog, as evidenced by the Nurses' Notes; however, this was not addressed in the written plan of care for this resident. 41. An interview at 9:55 AM with Resident #2 revealed that she remembered leaving the facility. When asked how she left she stated, "I just walked out the front door and followed a car out. I was looking for my dog. I was walking up and down the street and the police brought me back, it was in the middle of the day. " 42. An interview on 8/16/07 at 11:45 AM with the facility's Administrator and LPN revealed that Resident #2 is usually walking the hallways and follows her around the halls. 10 The LPN stated that at 1:00 PM she woke the resident to give her medication. The LPN stated she did not see the resident after that and was unaware that Resident #2 left the facility until they got a call from the police department. When Resident #2 was brought back to the facility she was scared, crying, shaken up and dehydrated. 43. An interview on 8/16/07 with the DON at 11:55 AM revealed that she received a phone call from the Sheriff's Department at 4:50 PM and was told that Resident #2 was found wandering on Lake Worth Road. 44. A review of Resident #2's clinical record on 8/16/07 did not show evidence of a facility search or a call to the police department to report the resident missing. 45. At 12:20 PM on 8/16/07, Resident #2 was observed near the nursing station asking to go outside as she was cold. She was given the dog's leash and was let out the front door by the maintenance man unaccompanied. 46. At 12:25 PM an interview with the MDS coordinator revealed that the facility does not use the code alert bracelet (Wander-guard system), the Certified Nursing Assistants (CNAs) watch the residents in the hall. An interview with the DON at 5:30 PM confirmed that the staff walk the hallways and look into rooms, they do not document that they have seen the patients. 11 47. On 8/16/07 at 8:30 AM, two surveyors arrived at the facility and observed the following while standing in the parking lot facing the facility entrance: a chain link fence was attached to the Independent Living Building and the Chapel, with an unlocked gate to the left of the Chapel. One door to the Chapel was visible through the gate in close proximity to the chain link fence; and another door was observed on the right side of the Chapel, which had no barriers and opened directly into the parking lot. 48. The surveyors entered the building at 8:33 AM, and informed the Director of Nursing (DON) that they wished to tour the facility and test the alarms on the doors. The DON accompanied one surveyor to the Matthew Hall. A Licensed Practical Nurse (LPN) accompanied the other surveyor to the opposite hall. At this time, the surveyor observed that the monitor screen, located at the nursing station in the health care center, which monitors the entrance gate to the facility property was turned off. 49. One surveyor entered Matthew Hall accompanied by the DON at approximately 8:36 AM and entered the Chapel. The surveyor observed that there were two doors, one on either side of the altar at the front of the Chapel. The doors had a mechanism that when pushed, the doors opened. The surveyor observed that there were no locks and/or alarms on either Chapel door. The DON confirmed that there were no locks or 12 alarms on either Chapel door and that a resident could exit the facility through the Chapel doors. 50. At 8:41 AM, the surveyor and DON approached the doors at the end of Matthew Hall. The surveyor asked the DON to test the door alarm. The surveyor observed a red LED light on the alarm pad was visible. The DON pushed the door and the door opened. The alarm did not sound. The DON confirmed that the LED light was red indicating that the alarm was functioning and that the alarm did not sound and the door was not locked. 51. The surveyor then entered the Restorative Dining Room in Matthew Hall. This door exited to an enclosed courtyard. The courtyard was bordered by the Independent Living Building. There was no lock and/or alarm on this door. The DON confirmed that there was no alarm or lock on this door. 52.. In the meantime, the other surveyor and Licensed Practical Nurse (LPN) went to John Hall. At 8:35 AM the LPN was asked to try to open the door in John Hall leading to the front parking lot. The LPN was able to open the door without the alarm sounding. The surveyor waited for the alarm to reset and tried a second time, again the door alarm did not sound. The surveyor and staff tried a third time and were in agreement that the alarm was not sounding. AHCA continued the tour to Luke Hall and the LPN was asked to try to open the 13 door on the north side of the building leading to the outside. The alarm did not sound on the first try. The surveyor waited for the alarm to reset and tried again; the alarm did not sound. We reset the alarm and tried a third time and were in agreement that the alarm did not sound. 53. At 8:48 AM, the two surveyors, accompanied by the DON and the Nurse, continued together to the Mark Hall doors. The double doors to the service area were observed to have an alarm pad, whose LED light was red. A facility maintenance staff person, a floor housekeeper and a food service employee arrived and stood behind the two surveyors, the DON and the Nurse. The surveyor asked the Maintenance Staff to confirm if the alarm was functioning. The maintenance staff person pointed to the red LED light and stated, "It's on." The surveyors pushed the doors, which opened and no alarm sounded. The surveyors asked the maintenance person to reset the alarm and test it again. The maintenance person reset the alarm and then tested it himself. The door alarm did not sound, and the door opened. The maintenance staff was able to walk through the door. The maintenance staff person reset the door for the third time, waited and then retested the door. The door failed to alarm and lock on this third attempt. The DON, nurse, facility maintenance staff person, and housekeeping floor staff person all confirmed that the door alarm did not lock and did not sound on any of the three attempts. 14 54. The two surveyors, DON, nurse and maintenance person walked through the double doors. To the right of these doors, the surveyors observed the door to the parking lot. The DON stated that this is the door that facility staff members use to enter the facility. There was no alarm or lock on this door. 55. At 8:55 AM, the surveyor, accompanied by the Maintenance Director continued outside the building to observe the perimeter of the facility. The surveyor observed that there were multiple residences at the back of the facility. A chain link fence was observed between the facility and these residences. The chain link fence was down and there were multiple tree trunks near the fence on the ground. 56. The surveyor continued to walk around the outside of the facility accompanied by the Maintenance Director. The surveyor observed the chain link gate to the left of the Chapel open at 9:06 AM. 57. At 9:10 AM, the group went to the front door, which was identified as locked and alarmed by the facility maintenance man, and tried to exit the building. The door alarm did not sound and the door opened. The surveyor waited for the alarm to reset and tried to exit two additional times. All three times the door alarm did not sound. This door leads to the front parking lot facing the electronic gate, which exits the property. 15 58. In summary, the surveyors found that the exit doors at the facility opened when pushed, and the alarms did not sound. The surveyors confirmed that the doors that were tested had red LED lights indicating that the alarms’ were functioning. 59. At 9:41 AM, the surveyor entered the doors to the Independent Living (IL) section of the facility and observed that the monitor to the front entrance gate was turned off. The surveyor asked the receptionist why the monitor was turned off. The receptionist stated, "It was hit by lightning two days ago. It doesn't work, so we turned it off." When asked what do you do if the bell is pushed to gain entrance to the facility. The receptionist stated, "I just buzz them in if I hear a bell." The surveyor asked if there is anyone watching to see who goes in or out of the gates. The receptionist stated that he/she did not know. 60. At 10:10 AM, the Owner/Administrator entered the MDS Office and stated to the two surveyors, "Show me the doors that don't work." 61. The two surveyors entered the hall and followed the Owner/Administrator to the Luke Hall exit doors. The Owner/Administrator pushed on the left door and it did not open, and did not alarm. The Owner/Administrator pushed the right door and the alarm sounded. A third attempt by the Administrator confirmed that the left door did not alarm. The 16 surveyor asked the nurse to confirm what had occurred during the previous tour. The nurse confirmed that the door alarms had not sounded and had not locked. 62. On Thursday, 8/16/07 at 11:40 AM, a repairman was observed outside at the electronic exit gate, working on the camera and gate. When questioned, the Administrator stated the system needed to be repaired because it was struck by lighting Monday evening (8/13/007). While touring the Independent Living portion of the facility with the Administrator, at approximately 12:30 PM, the surveyor observed that the monitor at the nurse’s station was off. The Administrator turned it on and fixed it so an image of the front electronic gate appeared on screen. 63. An interview with the DON at 2:40 PM revealed that there is no facility policy requiring the staff to watch the monitors at the nurses’ station, “there is usually someone at the desk to observe”. 64. The Security policy for the facility states "the facility will develop a procedure to maintain and test all security equipment”. a) The plant director or designee will maintain an inventory of all security equipment. b) The plant director will establish the frequency of testing and maintenance of security equipment. c) The plant director will maintain a checklist for all security equipment testing and maintenance. 65. At 3:15 PM an interview with the Maintenance Director regarding the procedures for testing and maintaining 17 the alarms revealed that they visually check the doors to see if the red light is on that means the door is alarmed. There is no log that documents the day, time, or frequency of when the doors are tested or checked. 66. On 8/16/07 at 9:35 AM, the surveyors requested that the Director of Nursing and MDS Coordinator provide the following documents for review: Facility layout List of current residents Elopement Policy and Procedure Copies of the Elopement Risk Assessments on the 48 current residents * A list of the residents the facility has identified as being at risk for elopement e+ + + 67. At 10:50 AM, the DON provided the surveyors with the following documents: * The facility layout map * A list of the 48 current residents. * A staffing document for 6/10/07, 8/10/07 and 8/16/07. * 39 (thirty-nine) Elopement Evaluation Screening Forms. 68. The surveyors compared the 39 Elopement Evaluation Screening to the list of 48 residents and determined that they had not been provided the forms for 9 residents including Residents #1, #2, #4, and #6. 69. At 4:40 PM, an interview with the DON revealed that the facility had 5 residents identified as elopement risks and their photo and Elopement Evaluation Screenings were kept in a binder in her office. On the survey date, 8/16/07, the 18 facility identified 4 additional residents as elopement risks. Their photos were taken on the survey date and will be included in the elopement risk binder. Resident #2 was 1 of the 4 residents who was going to be added to the binder. 70. Based on the foregoing, The Crossings violated Section 400.102(1) (a), Florida Statutes, herein classified as a patterned Class I deficiency pursuant to Section 400.23(8) (a), Florida Statutes, which carries, in this case, an assessed fine of $12,500.00. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). 71. The Agency, in addition to any administrative fines imposed, may assess a survey fee of $6,000.00 pursuant to Section 400.19(3), Florida Statutes. The fine for the 2-year period shall be $6,000.00, one half to be paid at the completion of each survey. DISPLAY OF LICENSE Pursuant to Section 400.23(7) (e), Florida Statutes, The Crossings shall post the 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. The Conditional License is attached hereto as Exhibit MAY 19 CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $12,500.00 against The Crossings on Count I for a pattern deficiency. Cc. Assess and assign a conditional license status to The Crossings in accordance with Section 400.23(7) (b), Florida Statutes. D. Assess a survey fee in the amount of $6,000.00 in accordance with Section 400.19(3), Florida Statutes. E. Grant such other relief as this 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 (2007). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922- 5873. 20 RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECERIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE WACTS ALLEGED IN f THE COMPLAINT AND THE ENTRY OF A FINAL ORDER PY THE ie Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 N.W. 52" Terrace Miami, Florida 33166 Copies furnished to: Diane Reiland Field Office Manager Agency for Health Care Administration 5150 Linton Boulevard, Suite 500 Delray Beach, Florida 33484 (Interoffice Mail) Karen Davis Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 {Interoffice Mail) Skilled Nursing Facility Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 {(Interoffice Mail) 21 EXHIBIT “A” Conditional License License No. SNF 1219096 Certificate No. Effective date: 08/16/2007 Expiration date: 01/31/2008 22 14710

Docket for Case No: 07-005498