7Ou. 2690 O000 5526 2841 STATE OF FLORIDA Ge AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, O ys: 039 | AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2007013974 INNOVATIVE HEALTH CARE PROPERTIES, INC., d/b/a SUMMER BROOK HEALTH CARE 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 INNOVATIVE HEALTH CARE PROPERTIES, d/b/a SUMMER BROOK HEALTH CARE CENTER, (hereinafter “Respondent”), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $12,500.00, based upon the Respondent being cited for one (1) patterned Class I deficiency pursuant to Section 400.23(8)(a), Florida Statutes (2007) and a survey fee in the amount of $6,000 pursuant to Section 400.19, Florida Statutes (2007). JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.569 and 120.57, Florida Statutes, and Chapter 400, Part II, 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 state statutes and rules governing skilled nursing facilities pursuant to Chapters 400, Part II, and 408, Part II, Florida Statutes (2007), and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a ursing home, located at 5377 Moncrief Road, Jacksonville Florida 32209, and is licensed as a skilled nursing facility, license number 1132096. 5. Respondent was at all times material hereto, 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 herein. 7. Pursuant to Florida law, an intentional or negligent act materially affecting the health or safety of residents of the facility shall be grounds for action by the agency against a licensee. § 400.102(1), Florida Statutes (2007). 8. On 11/26/2007, Immediate Jeopardy was identified and considered to be on- going. Based on record review and staff interview, the facility failed to provide the supervision and monitoring needed to prevent a cognitively impaired resident from elopement/exiting the facility. Furthermore, based on observation, record review and staff interview, the facility continues to fail to provide the supervision and monitoring needed to ensure the safety of 13 additional residents assessed as at risk for elopement. The residents at risk are sampled Residents #1, 2, and 3 and 11 unsampled residents. The findings include: 9. A review of the medical record for Resident #1 on 11/26/07 revealed the resident was admitted to the facility on 2/19/07 and readmitted on 3/12/07. The resident had a diagnosis of right thigh abscess and dementia. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated 11/19/07, revealed the resident had both long and short term memory problems and was moderately impaired in decision making. The MDS revealed the resident wandered and that the wandering behavior was not easily altered. 10. A review of the resident's care plan, last reviewed by the facility on 11/19/07, revealed the resident was care planned for risk of elopement, wandering and refusal to wear a Wanderguard. The care plan for each of these concerns included the staff to monitor the resident's whereabouts every 30 minutes. A nurse’s note dated 10/23/07 revealed the resident wanted to leave the facility and threatened to kill himself and others if he/she could not leave. A nurse’s note dated 11/3/07 revealed the resident was found standing by the elevator stating he/she wanted to leave and to go "to the shelter." A nurse’s note dated 11/11/07 revealed the resident had repeatedly pushed the elevator button and told the nurse he/she was "going to the shelter." A nurse’s note dated 11/19/07 revealed the resident pushing the elevator button several times shouting he/she "wanted to go to the shelter now." A nurse’s note dated 11/22/07 revealed the resident walked to the back elevator 3 times to get on the elevator shouting "I want to go to the shelter now, now.” A nurse’s note dated 11/25/07 at 5:10 am revealed the resident was successful in eloping from the facility. As of 11/25/07 at 5:00 pm the nurse’s notes revealed the resident had not been found. 11. An interview with the Unit Nurse on 11/27/07 at 5:58 am, who worked with Resident #1 on 11/25/07 prior to his elopement revealed the resident was observed near the elevators earlier in the shift and was sent back to his/her room. The nurse further revealed she had gone into another resident's room to do a tube feeding. When the nurse had completed what she was doing for the tube feeding she left the room and went to another resident's room to do a tube feeding. The nurse states at this time another resident came to her and told her Resident #1 went into the elevator. The nurse was unable to determine the time the resident left in the elevator. 12. No written evidence could be found to indicate whether the resident's whereabouts is monitored every 30 minutes. 13. An interview with the Director of Nursing (DON) on 11/26/07 at 12:20 pm revealed the facility does not record the 30 minutes monitoring for any resident who is at risk for elopement. 14. An interview with the DON on 11/26/07 at 3:54 pm revealed the facility had an "Elopement Book" with the identities of 14 residents who were at risk for elopement residing at the facility. The DON stated residents who are an elopement risk are care planned for 30 minute monitoring. A review of the "Elopement Book" on 11/26/07 revealed the names of sampled Residents #1, 2 and 3. Further review of the book revealed 10 of the residents with risk for elopement lived on the 3rd floor and 4 of the residents with risk of elopement lived on the 2nd floor. 15. An observation on 11/26/07 at 10:44 am in the ground level smoking area, revealed 13 residents. No staff were observed in the smoking area. One staff person was observed to be about 30 yards away standing with her back to the smoking area, looking through a fence. When interviewed, on 11/26/07 at 10:46 am, the CNA stated she was to monitor residents in the smoking area but that whenever she had this duty she would go to the area in which she was previously standing and watch a heron with stick legs in the creek. Three of the 13 residents in the smoking area were later identified as being at risk for elopement. 16. Aninterview with a 3rd floor CNA on 11/26/07 at 3:56 pm revealed the CNA could only identify 4 of the 10 residents who were at risk for elopement. Furthermore the CNA did not seem to be aware of the residents requiring monitoring every 30 minutes as she stated she does her rounds every 2 hours. 17. Aninterview with another 3rd floor CNA on 11/26/07 at 4:12 pm revealed the CNA could not identify which residents on the third floor were care planned for elopement or that their care plans called for the residents to be monitored every 30 minutes. 18. An interview with another 3rd floor CNA on 11/26/07 at 4:23 pm revealed the CNA could not identify which residents on the 3rd floor were at risk for elopement. 19. Aninterview with the 3rd floor Unit Nurse on 11/26/07 at 4:32 pm revealed the nurse was unaware of the 30 minute monitoring of residents who are at risk for elopement as she stated she ensures CNA's monitored those at risk "every hour". This nurse was able to identify 6 of the 10 residents on the 3rd floor at risk for elopement and therefore had a care plan for monitoring every 30 minutes. 20. An interview with a CNA on 11/26/07 at 4:47 pm, in the facility outside resident smoking area, revealed the CNA had worked at the facility for a week and did not know if any of the residents in the smoking area were at risk for elopement. Two of the residents in the smoking area on 111/26/07 at 4:47 pm were identified in the facility's "Elopement Book”. 21. Upon entering the facility on 11/27/07 at 4:40 am, the front door was unlocked and a man was seated in a chair facing the entry door. The man wore a hat that said "security". Seated approximately 10 feet from the man was a resident (#4) who was identified in the "Elopement Book" as at risk for elopement. When interviewed later that morning at 5:25 am, the security man stated he did not know which residents were at risk for elopement. He also stated he doesn't always sit at the door as he makes rounds, and takes breaks. He further stated he did not see Resident #1 the moming he/she eloped. He also stated residents could leave the building by one side door that did not have an alarm as well as the front door. 22. An interview with the 3rd floor Unit nurse on 11/27/07 at 4:46 am revealed the nurse was only able to identify 5 of the 10 residents on the floor who were at risk for elopement. 23. During observations on the 3rd floor on 11/27/07 at 5:02 am, a CNA produced an Elopement Book that had the list of residents on the 3rd floor who were at risk for elopement and produced a sheet in the book that had 30 minute increments. The CNA stated the facility had started this check sheet for 30 minute monitoring of the whereabouts of those at risk for elopement. The CNA stated this was the first time she had used this sheet as it was just implemented the evening before, 11/26/07. 24. During an observation on 11/27/07 at 5:12 am on the 2nd floor, the floor's Elopement Book, listing those at risk for elopement and a check sheet for 30 minute monitoring was observed . Spaces for the 4:30 am and 5:00 am monitoring were blank. During an interview with a Nurse on the 2nd floor on 11/27/07 at 5:15 am she was asked where a particular resident (#4) was (a resident at risk for elopement) the nurse looked in the resident's room (215B) and stated the resident may be in the bathroom or downstairs, then went about passing medications. Another nurse was then asked the whereabouts of the same resident, on 11/27/07 at 5:16 am and stated the resident may be downstairs on the smoking patio but she did not recall the resident telling her that he/she was leaving the floor. This is the same resident observed sitting by the front door, downstairs, at 4:40 am on 11/27/07 near a security person who did not know the resident was at risk for elopement. 25. During an observation in the facility's outside smoking area on 11/27/07 at 5:26 am the CNA responsible for the area and its residents left the area and was observed entering the building then entering the elevator. This CNA was observed retuming to the smoking area at 5:28 am on 11/17/07 and stating she was confused and did not know she was supposed to stay in the smoking area until 6:00am. The CNA has the 3rd floor 30 minute monitoring check list with her. 26. During an interview with a 3rd floor CNA on 11/17/07 at 5:35 am, the CNA stated the 3rd floor 30 minute monitoring form was not available to staff on the 3rd floor as the CNA who was monitoring the smoking area had taken it with her. At that time, 2 of the 10 floor’s residents at risk for elopement were observed in the smoking area. 27. A review of the 2nd floor's 30 minute monitoring form for residents at risk for elopement, on 11/27/07 at 6:00 am, revealed blank spaces for the 5:00 am and 5:30 am time increments. 28. A review of Resident #2's medical record on 11/26/07, revealed the resident had a care plan, reviewed by the facility on 11/19/07, for risk of elopement and had as an intervention 30 minute monitoring. No evidence could be found that the 30 minute monitoring was being done. 29, A review of Resident #3's medical record on 11/26/07, revealed the resident had a care plan, reviewed by the facility on 11/23/07, for risk of elopement and had as an intervention 30 minute monitoring. No evidence could be found the 30 minute monitoring was being done. 30. The whereabouts of Resident #1 was unknown at the time of the exit on 11/27/2007. 31. The Respondent has failed to take measures to ensure that appropriate protective and support services are provided to its residents who have been identified to be at risk of elopement or who exhibit exit seeking behaviors. 32. The facts illustrate a systematic failure in the provision of these services. Care plans to address resident issues are critical in meeting the needs of facility residents. Where the interventions crafted to address those needs are not implemented, resident needs are left unaddressed if not ignored. 33. Here Respondent has identified resident risks, but failed in the implementation of interventions to minimize those risks. Many direct care personnel are unaware of the residents who have been identified as at risk of elopement or who exhibit exit seeking behavior. The staff is not educated on the planned interventions of the Respondent to address the resident’s presented risks and as such have failed to do so. 34, Interventions not implemented are not protecting residents. Respondent was presented with affirmative behaviors indicating that a resident was desirous of leaving the facility. Respondent’s staff documented these expressions. Respondent failed, however, not only to respond to these affirmative acts, but to take steps necessary to ensure that planned interventions were implemented. 35. | The Agency determined Respondent's failure to provide supervision and monitoring needed to prevent a resident from eloping/exiting the facility is an intentional or negligent act that materially affects the health or safety of residents of the facility, in violation of Section 400.102(1), Florida Statues. 36. Furthermore, based on observation, record review and staff interview, the facility continues to fail to provide the supervision and monitoring needed and care planned to ensure the safety of 13 other residents at risk for elopement, a Class I patterned deficiency per Section 400.23(8)(a), Florida Statutes (2007). ‘ 37. The above mentioned deficiencies presents a situation in which immediate corrective action is necessary because the facility’s noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $12,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2007) for a patterned Class I deficiency. COUNT II 38. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 39. Respondent has been cited for one (1) Class I deficiency and one (1) Class II deficiency from a separate survey or complaint investi gations with a 60-day period, and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000.00 pursuant to Section 400.19(3), Florida Statutes (2007). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of $6,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2007). WHEREFORE, the Agency intends to Respectfully submitted this | [ay of December, 2007. C Sti Ny tan Z ALMAN, ESQUIRE Florida Bar I.D. No. 0030942 Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5403 (850) 922-5873 - Telephone (850) 921-0158 - Facsimile Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. 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, 323 08, (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 US. Certified Mail, Return Receipt No: 7000 0520 0024 8388 2010 on December \ 4* W 2007 to: Alfred Clark, Registered Agent, Summer Brook Health Care Center, 117.8. Gadsden St., Suite 201, Tallahassee, Florida 32301 and by U.S. Mail to Summer Brook Health Care Center, 5377 Moncrief Rd., Jacksonville, Fl. 32209. a > ae < Se Copies furnished to: Dewayne Harvey, Administrator Summer Brook Health Care Center 2445 Dunn Ave #1320 Jacksonville, Fl. 32218 Summer Brook Health Care Center Registered Agent. Alfred Clark (U.S. Mail) 117 S. Gadsden St., Suite 201 Tallahassee, Florida 32301 (U.S. Mail) Nancy Marsh Zaynab Salman, Esquire Field Office Manager Senior Attorney 921 N. Davis Street Bidg. A, Suite 115 Jacksonville, F]. 32209 Cnteroffice) Agency for Health Care Admin. 2727 Mahan Dr, #3 Tallahassee, Florida 32308 (Interoffice) Wt STATE OF FLORIDA AY AGENCY FOR HEALTH CARE ADMINISTRATION _ RE: INNOVATIVE HEALTH CARE PROPERTIES, INC. d/b/a SU HEALTH CARE CENTER . CASE NO: 2007013974 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter! 20, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-922-5873 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) | I admit to the allegations of facts contained in the Notice of Intent to Deny, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)__ I. dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28-106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees. License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) [hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: HOO Lt-szgt+iceze OO a ce fk ake od 00 0 0 AZ orsosoesEe BE-LT-T9IE7O-BEEOx 2zzovaeoeze :5a Guyn4od OL BTGYNN dassauddy s¢ B7aGHSALISa LON pesseyeye BORTT EY 9289 HSQNSS OL NANLSY ERE rm bOLETS ER Debs 7-H. ZB BEXEAL—-- PRO) 'S ANI ia ee HEREPSITY 7 ~~ ‘jueby pasoysibay JE28H YOOIg JEWS a, 40}U9D aeD 92 425s OOOO Obwe KOOe sove-woeze wpuo|s “sou py €# SIN “SAL UeYPIA LZLZ ; | | | tL VoH i U.S. Postal Service. CERTIFIED MAIL. 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Docket for Case No: 08-000221