STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, OV YOL AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008002592 (Fines.) 2008002610 (Cond.) DELTA HEALTH GROUP, INC., d/b/a GLEN OAKS HEALTH CARE, 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 DELTA HEALTH GROUP, INC., d/b/a GLEN OAKS HEALTH CARE, (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 Conditional commencing January 18, 2008 and ending March 3, 2008, impose an administrative fine in the sum of two thousand five hundred dollars ($2,500.00), based upon Respondent being cited for one isolated State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, 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, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 76-bed nursing home located at 1100 Pine Street, Clearwater, Florida, 33756, and is licensed as a skilled nursing facility, license number 1173096. 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. That pursuant to law, each resident has 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, with established and recognized practice standards within the community, and with rules as adopted by the agency. § 400.022(1)(1), Fla. Stat. (2007). 8. That on or about January 18, 2008, the Petitioner Agency completed an annual survey of the Respondent’s facility. 9. That based upon observations, interviews and the review of records, Respondent failed to provide adequate and appropriate care and protective and support services to prevent the development of pressure ulcers and or ensure adequate pain management for two (2) of twenty (20) sampled residents, the same being contrary to law. 10.‘ That the Petitioner’s representative reviewed Respondent’s records regarding resident number two (2) during the survey and noted the following: a. The nursing "Resident Admission - Data Collection Form" dated "8/3/07" recorded that the resident was admitted to the facility with "scabs on (b)(bilateral) feet." b. The diagram that accompanied the assessment is highlighted on the anterior (top) of the feet only; c. There is no documentation noted regarding impaired skin integrity on the heels or soles of the feet; d. The assessment also indicated that the resident suffered from "edema feet & legs.” e. The resident’s "Decubitus/Pressure Ulcer Risk, Observation & Record" dated "8/3/07" indicated a score of "7" which would indicate that the resident. was not considered a "high risk to develop pressure ulcers”. f. Physician's orders, dated September 11, 2007, directed "D/C skin prep to (L) heel. (L) heel - cleanse with NS (normal saline), apply Bactroban (antibiotic ointment) and cover with dry drsg (dressing) qd (every day) & prn (as needed) for Stage II. Wound care consultant (name) to evaluate and tx (treat) (L) heel". g. The wound care services’ (name) initial "Wound Care Assessment", dated September 13, 2007, indicated two sites of concern: i. Site 1: Left heel. Etiology Pressure. Exam: 7.0 c.m. x 11.0 c.m. x >(under) 0.2 c.m. 85% deflated blister. 15% gran (granulated). Initial stage: IT; ii. Site 2: Left plantar Etiology: pressure Exam: 4.0 c.m. x 3.0 c.m. (no depth) 100% DTI (deep tissue injury) Unstageable,” That the September 13, 2007 Wound Care Assessment reported "Assessment/Summary 2. W/C leg rests too short & causing deep tissue injury (DTI). Will have P.T. (physical therapy) eval. & lengthen. Recommendations 1. Lengthen W/C leg rests ASAP (as soon as possible)(Physical Therapy ?). 5. Keep legs elevated at all times. 6. Podus boot to Lt. foot". An undated nursing note, on or before September 13, 2007, indicated "Request to have W/C leg rests extended". Physician's orders for January 2008 revealed an order for "Podus boot to (L) foot at all times except for ADLs (activities of daily living)". Later wound care services' (name) “Wound Care Assessment" tools dated December 6, 13, and 27, 2007 and January 3 and 16, 2008 revealed that wound debridement (manual or chemical) had taken place on those dates with consistent recommendations to "off-load" the left heel and "elevate" left lower extremity while sitting. The resident's care plan, dated November 20, 2007 for "unstageable pressure ulcer on left heel" indicated as "Approach: 3. Complete wound treatment as per physician's order. 14. Podus boot (L) foot at all times except for ADLs". The December 2007 Treatment Administration Record indicated "Podus Boot to (L) foot at all times except for ADLs" with acknowledging signatures only noted on "12/1/07, 12/8/07, 12/29/07 and 12/30/07". n. The January 2008 Treatment Administration Record indicated the same order with an observed acknowledging signature on only "1/14/08.” 0. That resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) indicated that the resident had a physician's order, dated November 24, 2007, which provided "Medicate for pain for dressing changes and wound rounds." p. A second physician's order, dated November 24, 2007 prescribed "Propoxy- N/APAP *100*-650 tab (for Darvocet-N 100 tablet). Give 1 tablet PO (by mouth) every 4 hours as needed for pain in LT (left) heel". q. The Care Plan dated November 25, 2007 for "potential pain related to injury heel pain secondary pressure ulcer" indicated "Approaches: 2. Observe resident for nonverbal signs of pain. 5. Medicate as ordered". r. The December 2007 and January 2008 Medication Administration Records (MAR) revealed that pain medication was administered as documented only on December 1, 2, 4, 8, and 12, 2007, one dose each day. s. The December 2007 and January 2008 MARs for the documentation for the entry "Medicate for Pain for Dressing Changes and Wound Rounds" were blank.” 11. That Petitioner’s representative interviewed Respondent’s Director of Physical Therapy during the survey who indicated as follows: a. That the facility provided resident number two (2) with the wheelchair; b. That resident number two (2) was "initially only to utilize a wheelchair for long distance transport to activities/dining", but the resident began sitting in the wheelchair longer than the resident should have to watch television in the room; . That the resident would extend the resident’s leg onto the footrest causing pressure; That physical therapy was unable to safely extend the leg rests on the wheelchair and, therefore, resident number two (2) now has a recliner in the room to watch television. 12. That the Petitioner’s representative observed resident number two (2) during the survey and noted the following: a. That during the initial tour on January 15, 2008 at 9:30 a.m., the resident was sitting in a wheelchair in the resident’s room watching television, there were no leg rests observed on the wheelchair, and the resident did not have the resident’s left leg elevated: That on January 16, 2008 at 8:50 a.m., the resident was sitting in a wheelchair in the resident’s room watching television, not actively receiving or participating in activities of daily living (ADL) care, and did not have the physician-ordered Podus boot on, the left leg was not elevated, and the resident’s gauze dressed heel was directly resting on the floor; That on January 17, 2008 at 1:30 p.m., the resident was sitting in a wheelchair in the resident’s room watching television after lunch, and the resident’s wheelchair did not have leg rests and the resident’s left leg was not elevated; That on January 17, 2008 at 4:08 p.m., the resident was sitting in the recliner in the resident’s room, the chair was not extended into a reclined position, the resident did not have the physician-ordered Podus boot on, and the resident’s left heel was directly resting on a towel on the floor. The resident was not receiving ADL care or assistance during this observation; That on January 16, 2008 at 10:30 a.m., Respondent’s Licensed Practical Nurse (LPN) was observed as she performed wound care to a Stage III left heel pressure ulcer on the resident’s foot and the following was noted: i. The resident was lying on the left side facing the wall; ii. The resident turned to the LPN before the wound care began and stated that if the wound care "hurts", the LPN would not be allowed to continue; iii. That the LPN was not observed to assess the resident's pain status before initiating the treatment. That on January 17, 2008 at 11:20 a.m., the same LPN again was observed as she performed wound care to the resident’s Stage II left heel ulcer and the following was noted: i. The LPN positioned the resident on the left side facing the wall; ii. The LPN cleansed the wound with a normal saline flush and wiped with a dry gauze three separate times; iii. During the second flush/wipe, the resident picked lifted the resident’s head up from the bed, turned the shoulders, grimaced and yelled "Ouch!" iv. The LPN stated that she was "sorry" and that the heel must be "tender"; v. The LPN stated to the surveyor that the "heel was debrided yesterday”. 13. That immediately after wound care, the Petitioner’s representative interviewed resident number two (2) at 11:40 a.m. regarding the resident’s pain management who indicated that the resident’s left heel "hurts when you touch it". 14. That the Petitioner’s representative interviewed Respondent’s Director of Nursing, Corporate Nurse and Corporate Risk Manager during the survey who provided no further information. 15. That the Petitioner’s representative reviewed Respondent’s policy and procedure on "Pain Observation and Record", dated November 2001, which. indicated, inter alia, as follows "General Guidelines 2. If a patient states, or shows signs that he/she is having pain and does not currently have prescribed pain medication, or is not receiving relief from current type, dosage or frequency of pain medication...contact the attending physician to discuss pain observations and interventions and develop a plan of care to better control the pain". 16. That the above reflects Respondent’s failure to provide adequate and appropriate care and protective and support services to prevent the development of pressure ulcers and or ensure adequate pain management for resident number two (2) in Respondent’s failure to: a. Ensure that the multiple physician’s orders for the use of a Podus boot dating back to September 2007 were followed; b. Ensure that physician’s orders requiring the elevation of the resident’s foot were followed; c. Ensure that the resident’s pain was assessed and treated in accord with prescriptive directives; d. Follow its policy and procedure to effectuate interventions regarding pain; e. Ensure that the intervention of a reclining chair in the resident’s room was utilized to elevate the resident’s left leg while the resident sat in the room. 17. That the Petitioner’s representative interviewed resident number five (5),an alert and oriented individual, who indicated as follows: a. b. The resident was focused on getting a pain management consultation; The resident had been awaiting for the consultation for months; The resident indicated that the facility's Administrator and Social Service Director (SSD) had been talking to the resident about visiting a pain clinic, but that an appointment with a named physician was still pending. 18. That the Petitioner’s representative reviewed Respondent’s records regarding resident number five (5) and noted the following: a. The cumulative diagnoses, as listed throughout the medical record, revealed that the resident had a chronic neuro-muscular disease and chronic pain; Multiple Social Service notes, from July 25, 2007 through January 3, 2008, documented the resident's many concerns and issues, including chronic pain syndrome, mobility issues and mood/behavior issues; An October 10, 2007 note documented an appointment with the resident’s physician that day, noted that no additional medications were ordered, but no records of the physician notes of that visit or efforts to obtain and follow up on those notes were located; A November 6, 2007 Neurology Progress Note reflected that the physician had given the resident the names of two pain physicians; and the names were also listed on the physician's progress note; Absent from the records was any nurses' note on the day of the November 6, 2007 physician’s appointment and no explanation why the pain physician referral was not made; f. Absent from the records were any Social Service notes specific to the November 2007 neurology appointment and the recommended pain physicians; g. A January 3, 2008 Social Service note, however, documented the resident being upset that "nothing" has been done to schedule an appointment with a pain specialist. 19. That the Petitioner’s representative interviewed Respondent’s social services director, risk manager, director of nurses, and corporate nurse during the survey who indicated the following: a. That the resident had gone to a pain clinic in October 2007; b. That upon returning from the appointment, the resident indicated that the clinic had not ordered any new medications, which was documented in the October 10, 2007 Nurse's Note; c. That Respondent had received and had not pursued obtaining a progress note from the pain clinic; d. The resident was identified as having gone to an appointment with a neurologist on November 6, 2007 and the neurologist had recommended two physicians who the resident might see regarding pain control. 20. Following the interviews above, Respondent obtained the October 10, 2007 "New Patient Consult" report from the pain management specialist which provided as follows: a. The "Plan" section indicated that the resident was asking for narcotic pain medications at that time; and that the physician did not feel that the resident was a candidate for narcotic therapy; b. The report indicated that the resident should consult with an addiction specialist prior to considering any type of long-acting narcotic; c. The physician noted: "If [the resident] wouid like to pursue medication management, I would want [the resident] to see an addiction specialist and then make the decision as to whether I feel this is something that we may be able to help [the resident] with". 21. That absent from the Respondent’s record was any indicia that Respondent had acted upon the October 2007 physician direction for further consultation with addictions specialists or further follow up. 22. That absent from the Respondent’s records were any indicia that Respondent had acted upon the November 2007 physician direction for further consultation with the two listed pain physicians or further follow up. 23. That on January 16, 2008, Respondent’s social services director indicated that an appointment to the pain clinic was still pending due to the clinic's request for the resident's entire medical history, which he recently forwarded the requested information to the clinic. 24. — That the above reflects Respondent’s failure to provide adequate and appropriate care and protective and support services relating to pain management for resident number five (5) in Respondent’s failure to ensure that follow up physician appointments and consultations as ordered by the resident’s physicians were timely made and fulfilled. 25. The Agency provided Respondent with the mandatory correction date for this deficient practice of February 18, 2008. WHEREFORE, the Agency seeks 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)(b) and 400.102, Florida Statutes (2007). COUNT II 26. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein. 27. 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 (2008) commencing January 18, 2008 and ending March 3, 2008. Respectfully submitted this ay) day of March, 2008. : Bar’ No. 566365 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2007), 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. 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 USS. Certified Mail, Return Receipt No: 7007 1490 0001 6907 5459 on March Zt , 2008 to: Anne McMahon, Administrator, Glen Oaks Health Care, 1100 Pine Street, Clearwater, Florida, Florida 32502. Copies furnished to: Anne McMahon, Administrator Kimberly A. Seith | Glen Oaks Health Care Registered Agent 1100 Pine Street 2 North Palafox Street Clearwater, Florida, 33756 Pensacola, Florida 32502 (U.S. Certified Mail) (U.S. Mail) Patricia Caufman Thomas J. Walsh, II, Esquire Field Office Manager Senior Attorney §25 Mirror Lake Dr., 4" Floor Agency for Health Care Admin. St. Petersburg, Florida 33701 525 Mirror Lake Dr, 330G (Interoffice) St. Petersburg, Florida 33701 (Interoffice) 33756, and by U.S. Mail to Kimberly A. Seith, Reg. Agent, 2 North Palafox Street, Pensacola, / , II, Esquire

Docket for Case No: 08-001822