DIVISION OF ADMINISTRATIVE HEARINGS FILED DATE, 45 Seok STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, OD "4 p) as 5 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008002628 (Cond.) 2008002625 (Fine) LEESBURG REGIONAL MEDICAL CENTER, INC., d/b/a LRMC NURSING 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 LEESBURG REGIONAL MEDICAL CENTER, INC., d/b/a LRMC NURSING CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license s a skilled nursing facility, to change Respondent’s licensure status from Standard to Conditional commencing February 8, 2008, to impose an administrative fine in the amount of forty thousand dollars ($40,000.00), and to impose a survey fee in the amount of six thousand dollars ($6,000.00), based upon Respondent being cited for four (4) State Class I deficiencies. 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 120-bed nursing home, located at 700 North Palmetto Street, Leesburg, FL 34748, and is licensed as a skilled nursing facility license number 12990961. 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. COMMON FACTUAL ALLEGATIONS 6. That on or about February 4-8, 2008, the Agency conducted an Annual Survey at Respondent’s facility. 7. That the Petitioner’s representative interviewed resident number eight (8) during the survey, an alert and oriented individual, who indicated as follows: a. That the resident had been hit and slapped by resident number one hundred thirty-four (134) on February 1, 2008; b. That resident number eight (8) yelled for help; c. That employee number three (3) came to the resident's room when he heard the resident yelling for help; d. That employee number two (2) had asked resident number eight (8) why resident number eight (8) was crying and the resident told the employee that resident number one hundred thirty-four(134) had hit the resident; That resident number eight (8) was later told by employee number six (6) that e. resident number one hundred thirty-four (134) could not be watched all the time; f. That the resident is afraid that resident number one hundred thirty-four (134) will return to the room of resident number eight (8). 8. That the Petitioners representative interviewed Respondent’s employee number two (2) during the survey regarding the events related to the interaction of residents numbered eight (8) and one hundred thirty-four (134) who indicated as follows: a. That after lunch on February 1, 2008 employee number three (3) told her that resident number one hundred thirty-four (134) was in the room of resident number eight (8); That she observed resident number one hundred thirty-four (134) holding the wheelchair of resident number eight (8) very hard: That resident number eight (8) did not mention anything regarding having been struck by resident number one hundred thirty-four (134); That she told employee number four (4), the nurse supervisor, that resident number one hundred thirty-four (134) was in the room of resident number eight (8); That “I know [resident number one hundred thirty-four (134)] has slapped a patient before;" That another resident had slapped resident number one hundred thirty-four (134) for getting too close to the resident and that resident number one hundred thirty-four (134) had hit a female resident a while ago; g. That resident number one hundred thirty-four (134) does hit staff. 9. That the Petitioners representative interviewed Respondent’s employee number three (3) during the survey regarding the events related to the interaction of residents numbered eight (8) and one hundred thirty-four (134) who indicated as follows: a. That at around 11:45 AM on February 1, 2008, the employee was working across the hall from the room of resident number eight (8); b. That the employee heard resident number eight (8) calling for help and when responding saw resident number one hundred thirty-four (134) grabbing and hitting resident number eight (8); c. That resident number one hundred thirty-four (134) was holding resident number eight (8) very tight and that the employee saw resident number one hundred thirty-four (134) hit resident number eight (8) with fists; d. Employee number three (3) called for help because the grip of resident number one hundred thirty-four (134) could not be loosened from the wheelchair of resident number eight (8); e. That employee number three (3) told employee number five (5) on the north hall about the incident. 10. That the Petitioner’s representative interviewed the spouse of resident umber one hundred thirty-four (134) during the survey who indicated that the resident had "...grabbed another resident's arm the other day.” 11. That Petitioner’s representative reviewed Respondent’s records regarding resident number one hundred thirty-four (134) on February 5, 2008 and noted as follows: a. That an entry dated January 8, 2008 in the interdisciplinary progress notes that the resident "...was combative with staff and residents first half of morning shift - refused morn [morning] meds [medications]. For awhile - after settling down, resident did take meds;" b. Documented on February 5, 2008 at 2000 hours was the resident "... grabbing onto staff, squeezing, not letting go until resident is ready to ungrip;" c. The resident’s Minimum Data Set (MDS) with an assessment date of November 8, 2007 documents Behavioral Symptoms as follows: i. Wandering - Behavior of this type occurred daily and was not easily altered; ii. Verbally Abusive Behavorial Symptoms - Behavior of this type occurred 1 to 3 days in last 7 days and behavior was not easily altered; iii. Physically Abusive Behavioral Symptoms - Behavior of this type occurred 1 to 3 days in last 7 days and was not easily altered. d. The current care plans of the resident did not reflect any Care Plan to address the identified Behavioral Issues for the resident; e. Documentation dated July 6, 2007 reflected that the resident was "., combative and verbally abusive to the staff. MD (Medical Doctor) was notified, orders were received for Ativan 0.5mg IM (Intramuscularly) which was given. This medication helped only a little. " 12. That the Petitioner’s representative reviewed Respondent’s policy and procedure and noted the following in Respondent’s Nursing Standards Manual: Subject: Prevention and Reporting of Resident Abuse page 5 V. Reporting/Response B. All staff are responsible to report any finding of abuse 1. All staff who know, or has reasonable cause to suspect that a VULNERABLE adult has been or is being abused, neglected, or exploited shall IMMEDIATELY report such knowledge or suspicion to his or her supervisor, the facility's appointed designee, and The Abuse Hotline at 1(800)962-2873.The witness must call in, but may call in with his or her supervisor or the facility designee present. Subject: Prevention and Reporting of Resident Abuse page 1: "Abuse includes acts of omission." Neglect includes "failure of a caregiver to make reasonable efforts to protect vulnerable adult from abuse, neglect, or exploitation by others. Neglect is repeated conduct or single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury, or a substantial risk of death. Under IV, 2. c. "physical abuse may also be the result of poor supervision...(SIC)" 13. That the Petitioner’s representative interviewed Respondent’s Director of Nursing (DON) on February 6, 2008 who indicated as follows: a. That employee number three (3) saw resident number one hundred thirty-four (134) "tap" resident number eight (8) on the cheek with a fist and called for assistance; That when employee number two (2) responded to the call for assistance, she only saw resident number one hundred thirty-four (134) holding onto the wheelchair of resident number eight (8); That when employee number three (3) saw employee number two (2) talking to the nurse supervisor on the unit, employee number three (3) assumed employee number two (2) was telling the supervisor of the assault; That employee number two (2) only told the nurse supervisor that resident number one hundred thirty-four (134) was holding on to the wheelchair of resident number eight (8); That therefore, the incident was never reported and no investigation was immediately conducted. . COUNT I 14. The Agency re-alleges and incorporates paragraphs one (1) through thirteen (13) as if fully set forth herein. 15. That pursuant to Florida law, each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist.of: (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential; (b) A preliminary nursing evaluation with physician’s orders for immediate care, completed on admission; (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment. The facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment. Rule 59A-4.109(1) and (2), Florida Administrative Code. 16. That pursuant to Florida law, "Resident care plan" means a written plan developed, maintained, and reviewed not less than quarterly by a registered nurse, with participation from other facility staff and the resident or his or her designee or legal representative, which includes a comprehensive assessment of the needs of an individual resident; the type and frequency of services required to provide the necessary care for the resident to attain or maintain the highest practicable physical, mental, and psychosocial well-being; a listing of services provided within or outside the facility to meet those needs; and an explanation of service goals. The resident care plan must be signed by the director of nursing or another registered nurse employed by the facility to whom institutional responsibilities have been delegated and by the resident, the resident's designee, or the resident's legal representative. The facility may not use an agency or temporary registered nurse to satisfy the foregoing requirement and must document the institutional responsibilities that have been delegated to the registered nurse. Section 400.021(16), Florida Statutes (2007). 17. That based upon observation, interview, and the review of records, Respondent failed to ensure the development of and maintenance of written care plans for two (2) of twenty-seven (27) sampled residents, said care plans related to behavioral and communication issues, said failure being contrary to the requirements of law. 18. That the minimum Data Set for resident number one hundred thirty-four (134) identified Behavioral Symptoms of the resident which specifically identified behaviors of the resident relating to wandering, verbal abuse, and physical abuse. 19. Facility records document said behaviors of resident number one hundred thirty-four (134) during the period of residency including, but not limited to an occasion where the Respondent reported such verbally and physically assaultive behaviors to the resident’s physician, resulting in the prescribed administration of Ativan which was noted to have minimal effect. 20. That absent from the care plans which Respondent had completed for resident number one hundred thirty-four (134) was any care plans which addressed the identified behavioral issues of the resident. 21. That the Respondent failed to complete, maintain, and implement care plans addressing the behavioral issues of resident number one hundred thirty-four (134) despite the resident’s continuing documented and known behavioral issues. 22. That no interventions were formulated to minimize or otherwise control or monitor such behaviors, allowing the same to continue without planned interventions to protect resident number one hundred thirty-four (134), facility staff, visitors, and other residents from risks associated from such identified and known physical assaults, verbal assaults, and wandering. 23. That the Petitioner’s representative observed, on February 5, 2008, from 12:20 to 1:10 PM, resident number one hundred forty-eight (148) in the main dining room, noting that the resident did not speak to any persons, residents or staff, during the meal. 24. That on February 5, 2008, the Petitioner’s representative interviewed Respondent’s certified nursing assistant who served the meal to resident number one hundred forty-eight (148) who indicated as follows: a. That the resident does not speak English; b. That the resident speaks only Spanish; c. That only three (3) of Respondent’s staff speak Spanish, and that none of those Spanish-speaking staff members were working on that day; d. That in the room of resident number one hundred forty-eight (148) was a communication board, but such a device was not situated in the facility’s main dining room. 25. That the Petitioner’s representative reviewed the Respondent’s care plans for resident number one hundred forty-eight (148) during the survey and noted that no care plan indicated the use of a communication board to address the language barrier presented by the resident’s speaking only the Spanish language. 26. _ That the Petitioner’s representative interviewed Respondent’s unit nurse for the north wing, where resident number one hundred forty-eight (148) was situate, who indicated that the care plans for the resident did not provide for the use of a communication board for the resident in the resident room or in the dining room. 27. That Respondent, by and through its staff, knew or should have known of communication difficulty presented as a result of the inability of resident number one hundred forty-eight to communicate with persons who do not speak Spanish. 28. That Respondent failed to appropriately care plan for interventions necessary to ensure that the language barriers presented by resident number one hundred forty-eight were addressed by Respondent so that the effect of such barrier were minimized at all times between the resident and Respondent’s staff. 29. That the above reflects Respondent’s failure to fulfill its regulatory responsibility to complete, maintain, and implement resident care plans which will describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being, the same being contrary to law, said failures resulting in uncontrolled violent behaviors directed to staff and residents, and the inability of a resident to effectively communicate needs to staff, including but not limited to medical or emotional needs. 30. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or 10 was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 31. The Agency provided Respondent with the mandatory correction date for this deficient practice of March 8, 2008. COUNT I 32. The Agency re-alleges and incorporates paragraphs one (1) through thirteen (13) as if fully set forth herein. 33. That pursuant to Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following... The right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety. Section 400.022(1)(0), Florida Statutes (2007). 34. That pursuant to Section 415.102, Florida Statutes (2007): (1) "Abuse" means any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health. Abuse includes acts and omissions. : (2) "Alleged perpetrator" means a person who has been named by a reporter as the person responsible for abusing, neglecting, or exploiting a vulnerable adult. (4) "Caregiver" means a person who has been entrusted with or has assumed the responsibility for frequent and regular care of or services to a vulnerable adult on a temporary or permanent basis and who has a commitment, agreement, or understanding with that person or that person's guardian that a caregiver role exists. "Caregiver" includes, but is not limited to, relatives, household members, guardians, neighbors, and employees and volunteers of facilities as defined in subsection (8). For the purpose of departmental investigative jurisdiction, the term "caregiver" does not include law enforcement officers or employees of municipal or county detention facilities or the Department of Corrections while acting in an official capacity. (5) "Deception" means a misrepresentation or concealment of a material fact relating to services rendered, disposition of property, or the use of property intended to benefit a vulnerable adult. (8) "Facility" means any location providing day or residential care or treatment for vulnerable adults. The term "facility" may include, but is not limited to, any hospital, state institution, nursing home, assisted living facility, adult family-care home, adult day care center, residential facility licensed under chapter 393, adult day training center, or mental health treatment center. (15) "Neglect" means the failure or omission on the part of the caregiver or vulnerable adult to provide the care, supervision, and services necessary to . maintain the physical and mental health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, which a prudent person would consider essential for the well-being of a vulnerable adult. The term "neglect" also means the failure of a caregiver or vulnerable adult to make a reasonable effort to-_protect a vulnerable adult from abuse, neglect, or exploitation by others. "Neglect" is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death. 35. That based upon interview and the review of records, Respondent failed to prohibit neglect or abuse by failing to provide adequate supervision or other appropriate intervention of a resident with a known history of assaultive behavior from physically assaulting staff and one (1) of twenty-seven (27) sampled residents, the same being contrary to law. 36. That Respondent’s Nursing Standards Manual PREVENTION AND REPORTING OF RESIDENT ABUSE section under Purpose the Respondent defines Neglect as "The failure or omission on the part of the caregiver to provide care, supervision and services necessary to maintain the physician and mental health of vulnerable adult, including but not limited to, food, clothing, medicine, shelter, supervision, and medical services, that a prudent person would consider essential for the well-being of a vulnerable adult. This term also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult form abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical harm or psychological injury or a substantial risk of death." 37. That the Respondent knew or should have known that the behaviors of Resident number one hundred thirty-four (134) included verbally and physically assaultive behaviors. 38. That the Respondent knew or should have known that the verbally and physically assaultive behaviors of resident number one hundred thirty-four (134) placed the resident, other residents, staff, and visitors at risk of harm. | 39. That the failure to assess, devise interventions, and to implement interventions to minimize or eliminate known risks presented by the behaviors of resident number one hundred thirty-four (134) are acts or omissions that constitute the abuse or neglect of resident number one hundred thirty-four (134). 40. That the failure to assess, devise interventions, and to implement interventions to minimize or eliminate known risks, including but not limited to the failure to sufficiently supervise the resident as presented by the behaviors of resident number one hundred thirty-four (134) are acts or omissions that constitute the abuse or neglect of other residents who may be the victims of such behaviors of resident number one hundred thirty-four (134). 41. | That the Respondent failed to protect resident rights to be free from abuse or neglect, by act or omission, and failed to implement its policy regarding resident abuse or neglect in its failure, inter alia, to: a. Promptly report for abuse or suspected abuse; b. Provide sufficient supervision to protect resident number one hundred thirty- four (134) and other residents; c. Complete, maintain, and implement care plans to address the behavioral issues presented by resident number one hundred thirty-four. . 42. That these failures constitute abuse or neglect within the constrict of law and Respondent’s policy. 43. That the Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 44. The Agency provided Respondent with the mandatory correction date for this deficient practice of March 8, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statates (2007). COUNT IIT 45. The Agency re-alleges and incorporates paragraphs one (1) through thirteen (13) as if fully set forth herein. 46. . That pursuant to Florida law, each nursing home facility shall adopt, implement, and maintain written policies and procedures governing all services provided in the facility. Rule 59a-4.106(2), Florida Administrative Code. Each facility shall maintain policies and procedures in...nursing services and resident rights. Rule 59A-4.106(3)® and (x), Florida Administrative Code. 47. That pursuant to Section 415.1034, Florida Statutes (2007): (1) MANDATORY REPORTING.-- (a) Any person, including, but not limited to, any: 1. Physician, osteopathic physician, medical examiner, chiropractic physician, nurse, paramedic, emergency medical technician, or hospital personnel engaged in the admission, examination, care, or treatment of vulnerable adults; 2. Health professional or mental health professional other than one listed in subparagraph 1.; 3. Practitioner who relies solely on spiritual means for healing; 4. Nursing home staff; assisted living facility staff; adult day care center staff; adult family-care home staff; social worker; or other professional adult care, residential, or institutional staff; 5. State, county, or municipal criminal justice employee.or law enforcement officer; 6. An employee of the Department of Business and Professional Regulation conducting inspections of public lodging establishments under s. 509.032; 7. Florida advocacy council member or long-term care ombudsman council member; or ; 8. Bank, savings and loan, or credit union officer, trustee, or employee, who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge or suspicion to the central abuse hotline. 48. That based upon interview and the review of records, Respondent failed to ensure that potential abuse/neglect for residents occurred regarding an assault by another resident with a known history of aggressive behavior, the same being contrary to law and facility policy. 49. That Respondent’s Nursing Standards Manual PREVENTION AND REPORTING OF RESIDENT ABUSE section VII entitled “Investigation” provides as follows: "The charge nurse is responsible for notifying any alleged reports of abuse or neglect.” ; A. Notify the administrator and/or Director of Nursing of occurrence B. Talk with resident...about details (sic)" C. Talk to staff D. Talk to any witnesses. E. Initiate Incident Report/Abuse Investigation Report F. Report findings to Administrator and/or Director of Nursing. G. Notification of abuse registry 1(800)962-2873 50. That the Respondent failed to implement its Nursing Standards manual as the same relates to the reporting and investigation of abuse. 51. That Respondent’s staff members failed to report suspected resident neglect or abuse from those who observed the acts or omissions through those who were informed of said incidents. $2. That these failures create a serious and immediate threat to the health and well-being of the residents. 53. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class J deficiency. 54. The Agency provided Respondent with the mandatory correction date for this deficient practice of March 8, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT IV 55. The Agency re-alleges and incorporates paragraphs one (1) through thirteen (13) as if fully set forth herein 56. That pursuant to Florida law, the internal risk management and quality assurance program is the responsibility of the facility administrator. § 400.147(2), Florida Statutes (2007). Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include, inter alia, the development and implementation of an incident reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. Section 400.147(1)(d), Florida Statutes (2007). 57. That based upon interview and the review of records, Respondent failed to implement its internal risk management and quality assurance program to ensure that policies and procedures that prohibit neglect or abuse, and to investigate identified occasions of potential abuse or neglect are implemented, the same being contrary to law. 58. That Respondent’s Nursing Standards Manual PREVENTION AND REPORTING OF RESIDENT ABUSE section VII entitled “Investigation” provides as follows: "The charge nurse is responsible for notifying any alleged reports of abuse or neglect." A. Notify the administrator and/or Director of Nursing of occurrence B. Talk with resident...about details (sic)" C. Talk to staff D. Talk to any witnesses. E. Initiate Incident Report/Abuse Investigation Report F. Report findings to Administrator and/or Director of Nursing. G. Notification of abuse registry 1(800)962-2873 59. That absent from Respondents records were any indication of the following: a. That Respondent investigated the incident between residents numbered eight (8) and one hundred thirty-four (134) which occurred on February 1, 2008; b. That Respondent, by and through its agents, reported the incident between residents numbered eight (8) and one hundred thirty-four (134) which occurred on February 1, 2008 to appropriate officials and or agencies in accord with its policies; c. That Respondent took any action to protect resident number eight (8) from further assault by resident number one hundred thirty-four (134); d. That Respondent took any action to protect resident number one hundred thirty-four(134) from injury to self or others as a direct result of the resident’s identified behaviors related to verbal and physical assault. 60. That the above reflects Respondent’s failure to ensure that its administrator effectively implemented a risk management and quality assurance program as required by law. 18 61. That the failure to implement and maintain risk management and quality assurance programs is likely to result in situations where adequate supervision, or other interventions, are not provided for a resident with a known history of verbal and physical assaultive behavior, in situations where identified assaultive behavior results in the physical assault of other residents and staff, and the failure to protect residents who had been or could be the victim of such behavior such risks, each individually and collectively creating a serious and immediate threat to the well-being and safety of residents. 62. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 63. | The Agency provided Respondent with the mandatory correction date for this deficient practice of March 8, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT V 64. | The Agency re-alleges and incorporates Counts I through IV of this Complaint as if fully set forth herein. 65. Respondent has been cited for four (4) State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes (2007). 19 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). COUNT VI 66. The Agency re-alleges and incorporates Counts I through IV as if fully set forth herein. 67. Based upon Respondent’s three cited State Class I deficiencies, 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)(a), 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 (2007) commencing February 8, 2008. COUNT VIL 68. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and the remainder of this Complaint as if fully recited herein. 69. That the Agency shall revoke any license issued under Part II of Chapter 400 Florida Statutes (2007) for the citation of two (2) Class I deficiencies arising from separate surveys or investigations within a 30-month period. Section 400.121(3)(d) Florida Statutes (2007). 70. That the Respondent was cited with three (3) Class I deficiencies on an Agency complaint survey completed March 29, 2007. Said citations were the subject of an administrative complaint resolved by Final Order dated November 9, 2007, attached hereto as Exhibit “A.” 20 71. That the Respondent has been cited with four (4) Class I deficiencies on an Agency complaint survey completed February 4-8, 2008, the subject of this complaint. 72. That based thereon, the Agency seeks the revocation of the Respondent’s licensure. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate a skilled nursing facility in the State of Florida, pursuant to §§ 400.121(3)(d), Florida Statutes (2007). Respectfully submitted this / ¥ day f March, 2008. . Walsh, II, Esquire a No. 566365 Agericy 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), Florida Statutes (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. 21 CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has bey served by US. Certified Mail, Return Receipt No: 7007 1490 0001 6907 5428 on March [F _, 2008 to: Dixie Goodell, Administrator, LRMC Nursing Center, 700 North Palmetto St., Leesburg, FL 34748 and by U.S. Mail to Phillip Braun, Esq., Reg. Agent., 600 East Dixie Avenue, Leesburg, FL 34748. Copies furnished to: Dixie Goodell, Administrator LRMC Nursing Center 700 North Palmetto St. Leesburg, FL 34748 (U.S. Certified Mail) Phillip Braun, Esq. Registered Agent. 600 East Dixie Avenue Leesburg, FL 34748 (U.S. Mail) Kriste Mennella/Allison Hillhouse Thomas J. Walsh, II, Esquire Field Office Manager Senior Attorney 14101 NW Hwy 441 Agency for Health Care Admin. Suite #800 525 Mirror Lake Dr, 330G Alachua, FL 32615 St. Petersburg, Florida 33701 (U.S. Mail) (Interoffice) 22 Walsh, II, Esquire STATE OF FLORIDA FILED AGENCY FOR HEALTH CARE ADMINISTRATION , .. AHOA AGEHCY CLERK STATE OF FLORIDA, AGENCY FOR UN NOV tu A & 2g. HEALTH CARE ADMINISTRATION, AHCA Nos. 26 4 Petitioner, 2007003883 vs. CASE No. 07-2865 LEESBURG REGIONAL MEDICAL RENDITION NO.: AHCA-07- (08 3 -S-OLC CENTER, INC., d/b/a LRMC NURSING CENTER, Respondent. / FINAL ORDER Having reviewed the Administrative Complaint dated April 23, 2007, attached hereto and incorporated herein (Ex. 1), and all other matters of record, the Agency for Health Care Administration (“Agency”) has entered into a Settlement Agreement (Ex. 2) with the parties to these proceedings, and being otherwise well advised in the premises, finds and concludes as follows: ORDERED: 1. The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the — terms of the Settlement Agreement. 2. The Respondent shall pay, within thirty (30) days of the date of rendition of this Order, an administrative fine in the amount of twenty EXHIBIT A thousand dollars ($20,000.00). A survey fee of six thousand dollars ($6,000.00) shall be paid in accord with law. 3. Checks should be made payable to the “Agency for Health Care Administration.” The check, along with a reference to these case numbers, should be sent directly to: Karen Davis Agency for Health Care Administration Office of Finance and Accounting 2727 Mahan Drive, MS #14 Tallahassee, Florida 32308. 4. Unpaid fines pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available. 5. Conditional licensure is imposed commencing March 30, 2007 and ending May 10, 2007. 6. Each party shall bear its own costs and attorney’s fees. 7. The Respondent’s petition for formal administrative proceeding is hereby withdrawn. 8. The above-styled case is hereby closed. DONE and ORDERED this 7 day of , 2007, in Tallahassee, Leon County, Florida. Andrew C. Agwunobi, M.D., Secretary Agency for Héalth Care Administration A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED. Copies furnished to: Elizabeth Dudek Thomas J. Walsh II, Deputy Secretary Assistant General Counsel Agency for Health Care Admin. Agency for Healthcare Admin. 2727 Mahan Drive, Bldg #1, MS #9 Office of the General Counsel Tallahassee, Florida 32308 Sebring Building (Interoffice Mail) 525 Mirror Lake Drive North, #330G St. Petersburg, Florida 33701 (Interoffice Mail) Karen Davis : Susan St. John, Esq. Finance & Accounting Counsel for Respondent Agency for Health Care Admin. LRMC Nursing Center 2727 Mahan Drive, MS #14 P.O. Box Drawer 1759 Tallahassee, Florida 32308 - | 502 East Park Avenue (Interoffice Mail) Tallahassee, Florida 32301 I [| (U.S. Mail) Jan Mills Timothy P. Menton, Agency for Health Care Admin. Acting President and CEO 2727 Mahan Drive, Bldg #3, MS #3 Leesburg Regional Medical Ctr. Inc. Tallahassee, Florida 32308 600 East Dixie Avenue (Interoffice Mail) Leesburg, Florida 34748 (U.S. Mail) William H. Roberts Informal Hearing Officer Agency for Health Care Admin. 2727 Mahan Drive, Bldg. #3. MS #3 Tallahassee, Florida 32308-5403 (Interoffice Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of this Final Order was served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the f 7 day of Slbte-b0 , 2007. Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Building #3 Tallahassee, Florida 32308-5403 (850) 922-5873 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, . vs. Case Nos. 2007003901 (Cond.) 2007003883 (Fine) LEESBURG REGIONAL MEDICAL CENTER, INC., d/b/a LRMC . NURSING 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 LEESBURG REGIONAL MEDICAL CENTER, INC., d/b/a LRMC NURSING CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2006), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing March 30 2007 and impose an administrative fine in the amount of $37,500.00, and a survey fee in the amount of $6,000.00, based upon Respondent being cited for three State Class I deficiencies. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2006). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. EXHIBIT 1 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 120-bed nursing home, located at 700 North Palmetto Street, Leesburg, FL 34748, and is licensed as a skilled nursing facility license number 12990961. 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. | COMMON FACTUAL ALLEGATIONS 6. That on or about March 29, 2007, the Agency completed an Annual Survey at Respondent’s facility. 7. That the Petitioner’s representative reviewed the Respondent’s records, including medical records, relating to resident number twenty-two (22) during the survey and noted the following: a. That the resident was admitted on January 12, 2007; b. That the resident’s diagnoses included diabetes mellitus; c. A physician’s order dated January 12, 2007 required that the resident’s blood sugar levels (hereinafter “BS”) to be performed before meals and at bedtime; d. Included in the admission orders dated January 12, 2007 was a protocol for the nursing staff to follow in'the event the resident's blood sugar was low enough to warrant intervention, e. The order dated January 12, 2007 was listed as number three (3) of page two (2) on the Physician Order Sheet (hereinafter “POS”) and appeared as: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject % amp) BS (50 inject 1 amp) f. The medical record revealed the following BS for the resident on January 16. and 17, 2007 along with the annotated intervention performed by the nurse: 1/16/07 3:00 PM-11:00 PM Nurse 1635=65, Glass of Apple juice 1740=97, No interventions 2026=66, Glass of Apple juice 11:00 PM -7:00 AM Nurse 2330=43, Two glasses of apple juices 01/17/07 0008=31, Two apple juices and two orange juices 0021=42, Health Shake and 3 instant oral glucose 0058=30, No interventions documented 0132=33, Attempted to start IV 0143=38, Resident cardiac arrest, expired g That there existed no indication in the medical record review that the resident’s physician was notified of the resident’s low BS; h. That the interventions administered by the Respondent’s nurse are in clear conflict with the physician protocol. 8. That the Petitioner’s representative interviewed, on March 29, 2007, the Respondent’s nurse that served on the 11:00 PM to 7:00 AM shift for resident number twenty-two who indicated "...[D]id not do the protocol because the health shakes usually work” and, when asked why the physician was not called, stated "I never call the physicians but I would just send the residents to the Emergency Room if needed.” 9. That the Petitioner’s representative interviewed the physician of resident number twenty- two (22) on March 29, 2007 who indicated that he would have expected a telephone call from the Respondent’s 11:00 PM to 7:00 AM nurse for this resident concerning the resident’s low BS but did not get one. 10. That the Petitioner’s representative interviewed the Respondents director of nursing on . March 29, 2007 regarding the death of resident number twenty-two who indicated that the medical record, an unexpected death, was not reviewed by the Respondent as part of its quality improvement program. 11. That the Petitioner’s representative observed the Respondent’s administration of medications to residents on March 26, 2007, interviewed the medication nurse administering medications, and reviewed the Respondent’s records regarding residents, both current and former, and noted the following: — a. Resident number fifteen (15): i. At 8:35 AM, the prescribed medication, Zyvox, an antibiotic to treat the resident’s pneumonia, was not administered to the resident; ii. The physician’s order for the resident to be administered Zyvox to the resident was ordered on March 23, 2007 at 10:00 PM; iii. The medication nurse for this resident stated that the medication was not available from pharmacy yet and that the resident had not received any of the prescribed doses as of yet; iv. The medication nurse ultimately indicated that she called the pharmacy and was told they would have the Zyvox for the resident’s 8:00 PM dose on March 26, 2007. Resident number fourteen (14): i. ii. iii. That at 8:20 AM, the medication nurse for this resident flipped the Medication Administration Record (hereinafter “MAR”) over and wrote "Med out of stock, has reorder"; The medication nurse indicated that she did not administer the resident’s . prescribed Lactinex, a medication addressing diarrhea, as the facility does not have the pill form as ordered and that the resident will not take powdered form; The resident’s MAR indicated that the resident had not been administered the prescribed Lactinex for the previous fifteen (15) days; The resident’s MAR was annotated on March a1, 2007 at noon by a nurse "Has been reordered many times.” Resident number thirty-one (31): i. ii. iil. The resident had been prescribed a hypoglycemic protocol on March 13, 20/07 which provided as follows: Dextrose 50 % water Abboject BS(80=1/2 glass apple juice ) BS (70=1 glass apple juice) BS (60 inject 4 amp) BS (50 inject 1 amp) That recorded BS levels for the resident as recorded for the month of March 2007 documented the following: March 15, BS = 71; March 17, BS = 52; March 19, BS= 79; March 25, BS = 68; and March 28, BS = 67; That the resident’s MAR did not include any indicia that the prescribed hypoglycemia protocol and its interventions were administered or followed. d. Resident number thirty-five (35): i. il. iil. iv. The resident was admitted on February 11, 2007 at 6:30 PM; The resident’s MAR indicated physician’s orders for Rocephin, an antibiotic, Paxil, a medication for depression, and Colace, a stool softener; The MAR reflected that the resident’s Rocephin was not available or administered to the resident on February 12 and 13, 2007, that the resident’s prescribed Paxil was not available or administered on February 12, 2007, and that the resident’s Colace was not available or administered on February 13, 2007; The MAR reflected that no prescribed medications were administered to the resident until February 13, 2007, to days following the resident’s admission. e. Resident number thirty-our G4): i. ii. iii. The resident was admitted to the facility 0 on February 11, 2007 at 5:00 PM; The resident’s MAR reflected prescriptions for : Coreg, for blood pressure; Zocor, for cholesterol; Amaryl, for diabetes; Evista, to address osteoporosis; Avandia, for diabetes; Zoloft, for depression; and Colace, a stool softener; The MAR reflected that the resident’s Coreg, and Zocor, were unavailable and not administered on February 11, 2007; The MAR reflected that the resident’s Amaryl, Evista, and Avandia were not available and not administered on February 12, 2007; vi. The MAR reflected that the resident’s Colace was not available and not administered on February 13, 2007; The MAR reflected that none of the resident’s prescribed medications were available and administered to the resident until the 8:00 PM administration of medications on February 12, 2007, in excess of twenty-. four (24) hours after the resident’s admission to the Respondent facility. Resident number thirty-three (33): iii, The resident was admitted to the facility February 3, 2007 at 7:00 PM.; _ The resident’s MAR reflected prescriptions for Calcium, a supplement, Seroquel, for psychotic disorders, and Namenda, for Alzheimer’s disease; The MAR reflected that the resident’s Calcium was not available and not administered on February 13, 2007; | The MAR reflects that the resident’s Seroquel was not available or administered on February 13, 2007; The MAR reflects that the resident’s Namenda was not available or administered on February 13, 2007. Resident number twenty-eight (28): i. ii. iii. The resident was admitted on July 25, 2005; The resident’s diagnoses included diabetes mellitus, schizophrenia, hypertension, and psychotic disorder; The March 2007 MAR reflected physician’s orders for the resident’s blood sugar to be checked by accucheck before meals and at bedtime; Physician’s orders for insulin coverage on a sliding scale with Novolin R Insulin as follows: Blood Sugar 200-249 give 2 units . Blood Sugar 250-299 give 4 units Blood Sugar 300-349 give 6 units vy. The March 2007 MAR revealed the following blood sugars recorded at 200 and above; There was no documentation on the MAR that insulin coverage was given at these times: 3/1 @ 6:00 AM of 209 3/4 @ 11:30 AM of 207 3/10 @ 11:30 AM of 205 3/14 @ 11:30 AM of 225 3/18 @ 11:30 AM of 234 3/20 @ 11:30 AM of 219 4:30 PM of 213 8:00 PM of 245 3/24 @ 11:30 AM of 260 3/25 @ 11:30 AM of 230 3/26 @ 11:30 AM of 210 3/27 @ 8:00 PM of 227 vi. The MAR and resident records did not reflect that the insulin coverage prescribed by the physician in the sliding scale was administered to the resident as would be required under the physician’s protocol, vii. The Respondent’s unit manager indicated on March 29, 2007 that there was no proof whether nurses gave the insulin or not on those dates; viii. No other place where the medication administration was typically charted was produced, nor could such annotations be found. Resident number thirty (30): i. The resident was readmitted on March 1, 2007; ii. The resident’s diagnoses included insulin dependent diabetes mellitus, cardio vascular accident, dysphagia and decubitus ulcer, iii. The resident’s MAR included orders for blood sugar levels to be checked vii. by accucheck before meals and at bedtime: Physician’s orders directed sliding scale insulin coverage with Novolin R Insulin as follows: Blood Sugar 151-200 give 2 units Blood Sugar 201-250 give 4 units Blood Sugar 251-300 give 6 units The March 2007 MAR recorded the following blood sugars recorded at 151 and above: 3/3 @ 11:30 AM of 151 3/4 @ 4:30 PM of 172 3/7 @8 PM of 151 3/8 @ 4:30 PM of 210 3/9 @ 4:30 PM of 232 3/13 @ 8 PM of 192 3/16 @8PM of 173 3/19 @ 4:30 PM of 174 3/20 @ 4:30 PM of 218 3/22 @ 4:30 PM of 232 3/25 @ 11:30 AM of 168 3/26 @ 11:30 AM of 161 The MAR and resident records did not reflect that the insulin coverage prescribed by the physician in the sliding scale was administered to the resident as would be required under the physician’s protocol; The Respondent’s unit manager indicated on March 29, 2007 that there was no other place where the medication administration was typically charted or was further documentation of insulin medication administration provided. Resident number thirty-two (32): i. The resident was admitted February 4, 2007 at 7:30 PM; iil, vi. vii. . Upon admission. the resident’s physician ordered Preservision Softgels,a vitamin and mineral supplement, take 1 capsule by mouth 2 times daily, The resident’s MAR revealed the medication not given for either dose on February 5, 2007, and noted the medication was on order from the pharmacy; The resident’s physician ordered on February 5, 2007 Albuterol, a broncodilator, .83 mg/ml solution, and Ipratropium BR, for symptoms of bronchitis and emphysema, .02% solution, use 1 unit of each in updraft every 8 hours; The resident’s February 2007 MAR does not reflect that these two prescribed solutions were administered on the scheduled 11:00 PM administration times for the following dates: February 5, 9, 13, 15, 16, 17, 18, 19, 20, 22, 23, and 24, 2007; The resident’s MAR contained no documentation or nursing notes explaining or justifying the failure to administer the medications as ordered; The Respondent’s director of nursing indicated on March 30, 2007 that it appeared that the resident’s Albuterol was not administered on those dates and no further documentation was produced to reflect why the medication was not administered. Resident number seven (7): ii. The resident was admitted on March 13, 2007; That the resident’s diagnoses included esophageal cancer, status post il. vill. ix. xi. xii. radiation treatment and chemotherapy; Physician’s orders of March 13, 2007 are annotated on the MAR for Morphine Sulfate 15 mg Tab SA, substitute for MS Contin 15 mg SA, take 3 tablets every 8 hours; The resident's MAR reflects that on March 18, 20/07 the resident's 10 PM. dose was omitted; The MAR annotated as to the failure to administer the medication that "MS Contin was on order."; The resident’s MAR reflects that on March 19, 2007, the resident’s 6:00 AM and 2:00 PM were not administered; The Mar was annotated reflecting the reason the 2:00 PM dose was not administered was "not available from the pharmacy."; There was no explanation documented by Respondent’s nursing staff for the omission of the 6:00 AM dose on March 19, 2007; The MAR documented physician orders dated March 13, 2007 for Nystatin 100,000 U/ml suspension, an antifungal, swish & swallow, 1 teaspoon 4 times daily; The MAR reflected that the noon, 4:00 PM, and 8:00 PM doses were not administered to the resident on March 25, 2007; Documented on the resident’s MAR for the noon and 4:00 PM administration was "not available from pharmacy."; There was no explanation documented by nursing for the omission of the 8:00 PM dosage; xiii. The Respondent’s director of nursing indicated on March 28, 2007 that no further documentation could be provided to explain the omission of the resident’s medications. COUNT I 12. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11) as if fully set forth herein. 13. That pursuant to Florida law, all licensees of nursing homes facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident 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)(), Florida Statutes (2006). 14. That Florida law provides the following: “Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(b), Florida Statutes (2006). 15. That based upon observation, the review of records, and interview, the Respondent failed to ensure the resident's right to receive adequate and appropriate health care by failing to provide care and services in accordance with the resident's plan of care for eleven (11) of thirty-eight (38) residents reviewed. 16. That for each of the resident’s referenced, physician’s orders, a pivotal part of the resident’s plan of care, were not followed by the Respondent in its failure to provide and administer prescribed medications. 17. That each prescribed medication must be provided and administered in accord with physician’s orders, and the failure to provide physician prescribed care and services created a serious and immediate threat to the health and wellbeing of the residents as illustrated by failures, including but not limited to, the provision of medications pivotal in the regulation of disease processes including diabetes, emphysema, mental illness and pain management 18. That inclusive in these failures are the Respondent’s nursing staff failing to provide medication administration as ordered and in at least one resident, the Respondent’s nurse substituting her judgment as to appropriate diabetic interventions for that of the resident’s physician. 19. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in - Respondent's facility and cited Respondent with an isolated State Class I deficiency. 20. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 12, 2007. 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) and 400.102, Florida Statutes (2006). COUNT I 21. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11) as if fully set forth herein. 22. That pursuant to Florida law, all physician orders shall be followed as prescribed, and if not followed, the reason shall be recorded on the resident’s medical record during that shift. R. 59A-4.107(5), Florida Administrative Code. 23. That based upon observation, the review of records, and interview, the Respondent facility failed 1o administer physician ordered medications and further failed to consistently record the reason for non-compliance in the resident’s record. 24. That a threat to the health and safety of a patient is inherent in not administering his or her medication as prescribed. The conditions or symptoms for which the medication was prescribed remain unaddressed and could worsen. In addition, health care providers, including primary care physicians, consulting physicians and even emergency medical services personnel, oftentimes rely upon facility medication records in making decisions about a patient’s care and treatment. 25. That when medications are not administered, and the cause for such failure to administer is unknown, treatment providers lack necessary information to determine future medication prescriptive decisions. . 26. That where the Respondent fails to obtain medications for administration, it has violated the requirement that physician’s orders be followed. 27. That these failures create a serious and immediate threat to the health and well-being of the residents and were patterned throughout the facility. 28. | The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 29. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 12, 2007. 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) and 400.102, Florida Statutes (2006). COUNT J 30. The Agency re-alleges and incorporates paragraphs one (1) through eleven (11) as if fully set forth herein 31. That 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)(a), Florida Statutes (2006). 32. That based upon the review of records and interview, the Respondent intentionally or negligently failed to implement policies and procedures to prevent neglect by failing to ensure care and services to provide physician ordered medications and prescribed care for residents and failed to timely respond to resident needs when assistance is requested by residents. 33. That the Petitioner’s representative interviewed resident number nine (9) on March 26, 2007 who indicated that about a week prior the resident had an incontinent episode (bowel) in bed and it took forty-five (45) minutes to an hour to be cleaned, and that the resident is aware when the need to have a bowel movement arises, but had to wait and had the incontinent episode while waiting on the staff to assist. 34, That the Petitioner’s representative interviewed residents numbered nine (9), twenty-three (23), thirty-nine (39), forty-two (42), forty-three (43), and forty-four (44) en masse on March 27, 2007 each of whom reported the following: a. That they had experienced an incontinent episode within the past three (3) months; That prior to the incontinent episode, the residents had activate their call lights; That the call light was responded to and turned off by the responding staff member; That the responding staff member informed the residents that the staff member was not assigned to the resident and that the resident would have to await assistance from the staff member assigned to the resident; That the residents wait for assistance by their assigned staff member for a period of forty-five (45) minutes or more, necessitating the incontinent episode; That the residents’ later learned that their assigned staff member did not assist the resident as the staff member was on break or had not been told of the residents’ requests for assistance. 35. That the Petitioner’s representative interviewed Respondent’s certified nursing assistant number one (1) on March 27, 2007 who indicated as follows: a. That though nursing assistants are assigned room numbers to cover on their shift, everyone is supposed to assist if a nursing assistant goes on a break or if a resident call bell/light goes on when you are walking down the hall; b. That you never know why that light is on so you should answer it; c. That her assigned resident's have brought to her attention that they have been . made to wait for care to be provided while she has been on a break or busy attending another resident; d. That she informed nurses when this occurs. 36. That the Petitioner’s representative interviewed Respondent’s certified nursing assistant number two (2) on March 27, 2007 who indicated as follows; a. That regarding call bells/lights, her assigned resident's have reported to her that they have been made to wait for care to be provided while she has been on a break or busy attending another resident, b. That nurse's are made aware of when this occurs. 37. That the Petitioner’s representative reviewed the Resident Council minutes for March 20, 2007 which reflected that call lights are "not answered in a timely manner or they (staff) will say I'll get your aid or I'll be right back and not come back": 38. That the Petitioner’s representative reviewed the Respondent’s resident Grievance Log which was annotated on March 20, 2007 for the North, West and South wings that "Patient state " that the call lights don't get answered in a timely mamner and when the aides come they say they'll be right back and don't come back," and the “Follow-up section” indicated that “Referred to charge nurse for follow up timing of CNAs to answer call lights”. 39. That the Petitioner’s representative reviewed the facility's Nursing Standards Manual and noted that in the PREVENTION AND REPORTING OF RESIDENT ABUSE section under Purpose the Respondent defines Neglect as "The failure or omission on the part of the caregiver to provide care, supervision and services necessary to maintain the physician and mental health of vulnerable adult, including but not limited to, food, clothing, medicine, shelter, supervision, . and medical services, that a prudent person would consider essential for the well-being of a vulnerable adult. This term also means the failure of a caregiver to make a reasonable effort to protect a vulnerable adult form abuse, neglect, or exploitation by others. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical harm or psychological injury or a substantial risk of death.” 40. That these facts reflect intentional or negligent acts of Respondent through its agents and employees that effect the health and safety of residents in the staff’s failure to administer medications as ordered, the staff administration of interventions in contradiction of physician orders, the staff’s failure to ensure prescribed medications are available for and administered to residents as ordered, and the failure to render services to residents in response to call bells where the resident is in need of assistance for activities of daily living. 41. The Agency determined that this deficient practice presented a situation in which immediate corrective action was necessary because Respondent’s non-compliance had caused, or was likely to cause, serious injury, harm, impairment, or death to a resident receiving care in Respondent's facility and cited Respondent with an isolated State Class I deficiency. 42. The Agency provided Respondent with the mandatory correction date for this deficient practice of April 12, 2007. 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) and 400.102, Florida Statutes (2006). COUNT IV 43. The Agency re-alleges and incorporates Counts I through I of this Complaint as if fully. set forth herein. | 44. Respondent has been cited for three State Class I deficiencies and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of $6,000 pursuant to Section 400.19(3), Florida Statutes (2006). 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 (2006). COUNT V 45. The Agency re-alleges and incorporates Counts I through III as if fully set forth herein. 46. Based upon Respondent’s three cited State Class I deficiencies, it was not in substantial compliance at the time of the survey with criteria established under Part Il 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)(a), Florida Statutes (2006). 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 (2006) commencing March 30, 2007. Respectfully submitted this day of April, 2007. J. Walsh, 0, Esquire Bar. No. 566365 Agéncy 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), Florida Statutes (2006), 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. I HEREBY CERTIFY that a true and correct copy of the foregoing has bee US. Certified Mail, Return Receipt No: 7004 1350 0004 2776 0628 on April Ron Hollerand, Administrator, LRMC Nursing Center, 700 North 34748 and by U.S. Mail to Phillip Braun, Esq., Reg. Agent., 600 Bast FL 34748. CERTIFICATE OF SERVICE rved by 2007 to: St., Leesburg, FL / Thomas 3. Walsh, II, Esquire enue, Leesburg, Copies furnished to: James Wilson, Administrator LRMC Nursing Center 700 North Palmetto St. Leesburg, FL 34748 (U.S. Certified Mail) Phillip Braun, Esq. Registered Agent. 600 East Dixie Avenue Leesburg, FL 34748 (U.S. Mail) Kriste Mennella Thomas J. Walsh, II, Esquire Field Office Manager Senior Attorney 14101 NW Hwy 441 Agency for Health Care Admin. Suite #800 525 Mirror Lake Dr, 330G Alachua, FL 32615 St. Petersburg, Florida 33701 (U.S. Mail)

Docket for Case No: 08-002355