STATE OF FLORIDA Op . AGENCY FOR HEALTH CARE ADMINISTRATION “é Jy, “5 STATE OF FLORIDA, OX: Je T y AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008005347 (Fines) 2008005348 (Cond.) CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a Capital Healthcare Center, Respondent et) / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against CAPITAL HEALTH CARE ASSOCIATES, LLC, d/b/a Capital Healthcare Center, (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 April, 11, 2008, impose an administrative fine in the amount of $30,000, and a survey fee in the amount of $6,000, based upon being cited for two widespread 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 156-bed nursing home, located at 3333 Capital Medical Blvd., Tallahassee, Florida 32308, and is licensed as.a skilled nursing facility license number 1073096. 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. COUNTI RESPONDENT’S FACILITY NEGLECTED TO PROVIDE CARE AND SERVICES TO MEET THE RESIDENTS NEEDS. § 400.102(1), Fla. Stat. (2007) WIDESPREAD CLASS I DEFICIENCY 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That Florida Law provides the following: 400.102 In addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility; 8. That on April 9, 2008, through April 11, 2008, the Agency conducted three unannounced complaint surveys at Respondent’s facility. The complaint allegations were confirmed. 9. Based on observation, interview, record review and policy review the facility neglected to provide care and services to meet the residents needs for 15 of 19 sampled residents (#1,2,3,4,5, 6,7,8,9,10,11,12,13,14,15), which included inadequate supervision of the Starlight Program, inadequate staffing, failure to provide fall monitoring with implementation of the facility's fall policy and procedures and failure to follow Standard of Nursing Practice for the treatment and care ofa resident with a head injury which resulted in Resident's #1 condition deteriorating while at the facility with the ultimate outcome of death. The findings include: 1. An interview with the family member of Resident #1 on 4//9/08 at 11:15 A.M. revealed his family member (resident #1) had fallen on 3/27/08. He stated the resident fell out of the wheelchair and hit his/her head. He stated the facility told him the resident had been attending movie time and was in the Starli ght program at the time of the fall. He stated the resident sustained a large knot the size of a tennis ball on the forehead. He stated Resident #1 was taken to the hospital and diagnosed with a concussion. The resident was released back to the facility on 3/27/08. The family member stated the resident had a hi gh fever and had been unresponsive since 3/29/08. The resident was sent back to the Hospital on 3/31/08 and the hospital stated the resident had a stroke and bleeding in the brain as a result of the fall on 3/27/08. On 4/10/08 at 9:30 A.M. the family member stated to this surveyor that the resident had died in the hospital as a result of the injuries incurred at the facility. 2. During the initial tour of the facility on 4/9/08 at 11:35 A.M. the Administrator volunteered information concerning the recent fall of the Resident #1 with a hematoma to the head. He stated the facility had a large amount of falls but the numbers were improving. The surveyor questioned what measures the facility had put in place to decrease the number of falls. The Administrator stated there were no new measures put in place. He stated the facility had just ensured the current fall protocols were being followed. 3. On 4/9/08 at 12:15 P.M. the Director of Nurses (DON) brought the surveyor the medical record for Resident #1 and stated everything was in order. She stated she had already reviewed the record. She stated the resident fell on 3/27/08 and was sent to the ER for evaluation. Resident #1 was sent back to the facility with a diagnosis of UTI and change in mental status. She stated over the weekend of 3/29/08 and 3/30/08 the resident began spiking “temps”. She stated the staff were calling the DON and Advanced Registered Nurse Practitioner (ARNP) over the weekend as the resident declined. The staff called the DON on Sunday 3/30/08 and stated the resident was not responsive to name. On Monday (3/31/08) the DON stated she was on vacation but called the facility to check on the resident and was told of the status. She stated she instructed the staff to send Resident #1 to the Emergency Room. The resident was sent to Tallahassee Memorial Hospital (TMH) which had a neurosurgeon. The neurosurgeon stated the resident had a slow bleed and there was nothing that could be done for them. The DON stated she was the Risk Manager and Quality Assurance Coordinator for the 156 bed facility. She stated she had assumed these responsibilities as of approximately 2/29/08 after the previous Risk Manager left the facility. The surveyor and the DON reviewed the facility's investigation of the Resident #1's fall. She stated the resident was in the Starlight program when the fall occurred. She stated the CNA (Certified Nursing Assistant) stated the resident was attempting to cross their legs and the chair tipped to the side and the resident fell out of the wheelchair onto floor. The D.O.N stated the CNA was provided a coaching plan, after Resident #1 sustained the fall on 3/27/08. A "coaching plan" is the process in which the facility uses for staff discipline. The DON stated she had completed no further investigation or corrective action since the initial investigation. 4. On 4/9/08 at 1:38 P.M. an interview with a Starlight aide (#1) revealed they usually work with 10-12 residents, they are often understaffed in the Starlight program and even if there is only one aide available to work in Starlight, they work in Starlight alone. She stated she was working the day the Resident #1 fell. She said she had left to take 2 other residents back to their room and was not present when Resident #1 actually fell. 5. Interview with the 2nd Starlight aide (#2) on 4/9/08 at 1:45 P.M. During this interview she revealed they usually work with 8-10 residents in the Starli ght ‘program. She stated her shift is from 1-9 PM and after 7:00 P.M. she is the only staff member in Starlight. The aide stated on 3/27/08 she pushed the resident #1 in the wheelchair from Hall C to the Starlight area, which was in the restorative dining room (main dining room). When she entered the Dining Room another resident was stopped in the middle of the floor, blocking the pathway. The aide left Resident #1 to push the other resident out of the way. She stated her back was to Resident #1 when she fell. She said the activities lady yelled out to get the resident and when she turned around the resident was on the floor. She said the resident does not normally try to get up and it looked like the resident fell out of the wheelchair sideways. She stated the resident's wheelchair was upright and did not fall over with the resident. She stated the resident had foot rests on the wheelchair and the resident's feet where in the foot rest prior to the fall. She said during the time of the fall there were 8 residents in the Starlight area. She said that if the facility had provided more staff then the Resident #1's fall would not have occurred. A 2nd interview was conducted with Starlight Aide #2 on 4/10/08 at approximately 2:50 PM. the aide repeated the information as above and stated the facility needs more staff assistance in the Starlight Room and throughout the facility. She reported that she told the Administration staff that Resident #1's fall could have been prevented if there were more staff available to assist with the residents. She additionally stated that she often works alone because there is not enough staff. 6. Interview on 4/9/08 at 2:00 P.M. with the Activities aide stated she was previously the Staffing Coordinator and had been with activities 2 months. She stated the Starlight program is totally separate from Activities Program and some Starlight residents will attend some group activities. She stated she did observe Resident #1's fall on 3/27/08. She stated she was in the main dining room directing bingo for the residents in Activities. The Starlight residents were ina separate area off of the dining room. The aide stated she happened to glance up could see Resident #1 was falling. She stated the resident "Jerked" and fell "comer wise" The aide stated she had not worked with the residents in the Starlight Program until they began joining in Activities. The aide stated she had noted the residents in the Starlight Program require a lot of care and supervision. The aide stated the current staffing is not adequate to meet the needs of the residents in Starlight. 7. A review of the Resident #1's medical record on 4/9/08 revealed s/he was admitted to the facility on 12/4/07. The medical record revealed the following sequence of events from the resident's fall on 3/27/08 to hospitalization on 3/31/08. The nurse notes stated on 3/27/08 the aide called the nurse to the dining room. Resident #1 was found lying on the floor on his/her side. The resident was observed with a large hematoma to the forehead. The nurse documented the resident's upper extremities were "very stiff" and the resident was "keeping arms stretched out." The nurse documented the resident was not responding to name but "was breathing”. The resident was taken back to her room and placed in bed. The resident's Vital signs were B/P 209/110, 82, 16, 98.2. The resident began to answer to their name after she was taken to the room but was not oriented. The ARNP was contacted and gave orders to transfer the resident to the hospital. The resident vomited twice before the transfer to the hospital by ambulance. Resident #1 was discharged back to the facility with a diagnosis of Urinary Tract Infection and a Concussion. The resident arrived back at the facility on 3/27/08 at 7:45 P.M. The LPN documented on the resident was NPO (nothing by mouth) except for medications per the ER nurse. The nurse did not document how long the resident was to be NPO. The medical record did not contain a physician order for NPO. The medical record did not contain the Emergency Room discharge Instructions and orders. The LPN wrote an order for Cipro, an antibiotic for the Urinary Tract Infection, but no further new orders on 3/27/08. The LPN documented the resident with a hematoma to the left side of the forehead. The LPN completed no further assessment. On 3/27/08 at 8:15 P.M. the LPN notified the family member of the resident's status. The nurse assessed the resident's vital signs which were blood pressure 161/88, pulse 68, respirations 18 and temperature 97.7. The nurse did not complete any other assessment. On 3/28/08 at 12:15 P.M. the LPN documented the resident was sleeping most of the morning and would respond when name was called. The resident had to be fed soup and fluids. The nurse documented the Hematoma "small on forehead." The nurse documented vitals signs stable but did not list the vital signs. No further assessment of the resident's neurological status was completed. The medical record did not contain documentation of the resident's nutritional status to include the percentage of food consumed. The resident's ADL & Nutrition/Hydration Care Record was incomplete with the last entry on 3/19/08. The medical record did not indicate when the resident was removed from NPO status. On 3/28/08 during the 7-3 shift the aide listed the vital signs on the assignment sheet of blood pressure 160/88, pulse 76, temperature 98.2, and respirations of 20. The vital signs as listed here and below were obtained from the aide assignment sheets, which listed only vital signs. On 3/28/08 a Fall Action Team report was completed and signed by the LPN. The fall review did not mention the resident's head injury with interventions. The interventions listed were to monitor the resident more closely and keep the Head of the Bed up 40 degrees for 24 hours. There is not evidence these interventions were implemented and followed. The resident's care plan was not updated with new interventions after the fall of 3/27/08. On 3/28/08 at 7:30 P.M. the resident would respond to voice and touch. The LPN documented the hematoma to the "forehead has disrupted." Pupils were reactive to light. No further assessment of the resident's status was completed. On 3/29/08 there is no nursing entries in the nurse notes. The resident's Medication Administration Record (MAR) stated on 3/29/08 the resident refused morning medications. The medical record did not contain any communication of the resident's refusal to the physician or family member. The MAR on 3/29/08 revealed the nurses did not complete accucks at 1630 and 2100. The MAR for 3/29/08 is not consistent, with some medications initialed by the nurse as given, while others are initialed with a circle which indicates the medications were held. The back of the MAR does not provide further explanation which would clarify if the resident received their medications. On 3/29/08 during the 3-11 shift the aide documented on the assignment sheet vital signs of blood pressure 149/94, pulse 73, and respirations 22. On 3/30/08 at 9:10 P.M. was the first assessment by a RN since the resident's return to the facility on 3/27/08. The RN documented the resident was responding to Painful stimuli. The resident had a hematoma to the forehead. The resident's vital signs were temperature 102.4, blood pressure 190/100, Respirations 22 and poor appetite. The resident's pulse was not assessed. The RN contacted the ARNP which gave orders for lab work of CBC with diff, CMP and straight cath for UA and C&S, chest x-ray, blood cultures, Tylenol, IV fluids of D5 1/2 NS at 60 cc/hr, and changed the resident's antibiotic. On 3/30/08 during the 3-11 shift the aide documentation the assignment sheet the resident's vital signs were blood pressure 190/100, temp 101.4, pulse 95, and respirations 22. There is not documentation of the nurses notification, or if these are the vital signs the RN used for her assessment. (see above) On 3/30/08 at 10:40 P.M. the resident's IV fluids were begun. The temperature was rechecked which was 100.6. There was no further assessment or vital si gns. On 3/30/08 the vital sign record stated on 11-7 shift the vital signs were temperature 98.6, pulse 70, respirations 22, and blood pressure 155/88. On 3/31/08 at 12:01 A.M. the nurse documented the resident was hard to awaken. The resident would open their eyes and grasp hand. The resident's eyes were PERL (Pupils Equal and Reactive to Light). No further neurological or nursing assessment was completed. On 3/31/08 at 5:30 A.M. the nurse attempted twice to collect urine via a straight catheter. The nurse was unable to obtain the urine. The Physician was not notified. On 3/31/08 at 10:15 A.M. the nurse assessed the resident and found them unresponsive to name, verbal or painful stimuli. The resident's pupils were constricted. Blood sugar was 128, Blood pressure 160/80, pulse 88, respirations 24, temperature 100.6. The ARNP was phoned and stated to send the resident to the hospital. The Ambulance arrived at 10:40 A.M. and transported the resident to the hospital. The resident was diagnosed with an Intracranial (Occipital) Hemorrhage. 8. The record review revealed nursing neglect with a lack of assessment and nursing care for Resident #1 with a known head injury. According to the Lippincott Manual of Nursing Practice a concussion is an indirect injury to the brain. A concussion is a temporary loss of consciousness that results from a transient interruption of the brain's normal functioning. An intracranial hemorrhage is a significant bleeding into a space or a potential space between the skull and the brain. This is a serious complication of a head injury with a high mortality rate. The nursing interventions include an assessment of the level of consciousness which is the most sensitive indicator of a change in the resident's condition. The Glasgow Coma Scale is recommended which assesses eye opening, verbal response, and motor response. A change of 2 or more points may be significant and requires notification of the physician and reassessment of the resident's neurological status. The nurse should evaluate vital signs. Hypertension and bradycardia indicate an increasing intracranial pressure. Head- injured patients may have associated cardiac dysrhythmias, noted by an irregular pulse or a fast pulse. Changing patterns of respirations and elevated temperatures are associated with a head injury. The pupils should be assessed for unequal or unresponsive pupils. The resident should be monitored for confusion or personality changes, impaired vision, eyes appear sunken, seizure activity, rhinorrhea or otorrhea which is indicative of leakage of CSF. The resident should be monitored for periorbital ecchymosis with indicates anterior basilar fracture. The resident's fluid volume and IV fluids should be restricted. 9. A review of the facility's neurological assessment flow sheet revealed the following components of the neurological assessment: date, time, level of consciousness, pupil response, motor functions, hand grasps, movement of extremities, pain response, vital signs, observations of seizure activity, headaches, vomiting, and paralysis. The facility's fall procedure stated a neurological assessment is to be completed after a head injury. 10. On 4/11/08 at 10:30 A.M. the DON stated the resident was seen by the ARNP on 3/28/08. The last MD note in the medical record is dated 2/22/08. The DON stated she would have to locate the note. The DON stated the ARNP ordered labs on 3/28/08. The medical record contained an order for a CBC and BMP to be collected on 3/31/08. The order is signed by the LPN and does not contain the name of the physician/ARNP which ordered the lab, and if it was a verbal order or a telephone order. The ARNP did not write the order. 11. On 4/11/08 at approximately 12:00 P.M. the DON provided this surveyor an ARNP note dated 3/28/08 for resident #1. The DON stated she had called the ARNP and the ARNP brought a copy of the note. The ARNP’s note is a pre- printed note which is very similar to the other ARNP notes in the medical record. The progress note did not address the resident's fall on 3/27/08 and her new diagnosis of UTI and Concussion. The ARNP wrote mental status was baseline, but did not provide further assessment. The ARNP was phoned on 4/11/08 at approximately 12:15 P.M. The ARNP stated the facility had phoned her this morning and requested the note. The ARNP stated she did visit on 3/28/08 and the original note must be waiting to be filed. She stated she had just realized she did not document the resident had gone to the ER on 3/27/08. She stated she couldn't remember much about the visit but she thought the resident fell from a standing level. She stated she was not contacted again by the facility until 3/31/08 when the resident was sent to the Emergency Room. The ARNP could not recall if she gave any orders on 3/28/08. She could not recall if the resident had a history of falls or the resident's mental and neuro status on 3/28/08. The ARNP was asked if she gave the orders on 3/30/08 for the blood cultures etc. The ARNP stated she could not recall if she gave any orders but stated she "probably" gave some orders. She was asked why she ordered the blood cultures, IV and other labs. She stated she could not remember. 12. A review of the Starlight Program Guide Policy and Procedure. The Policy is located in the manual under "recreational and therapeutic activities." The policy stated the Starlight program is a structured program for cognitive enhancement, nursing rehabilitation and behavioral management provided for a small group of nursing facility residents. The objective of the program is to provide a safe, structured environment, consistent approaches and programming for persons with decreased cognitive function and impaired physical abilities. Outcome goals include: decreases injuries, decreased weight loss, relief of behavioral symptoms, maximized functional independence, and improved cognition. The program is provided by Nursing Assistants, monitored by the Activity Director and/or Nursing Staff provide most of the care and services provided. The program includes activity opportunities, ADL care that can be done in a public setting and behavior management. The Admission Criteria includes the resident is demonstrating behaviors associated with Alzheimer's and/or dementia such as, memory dysfunction, poor judgement, disorientation to time, place and person, decreased attention span, mood fluctuations, wandering and exit-seeking, expressions of anxiety, high risk for falls/accidents due to poor safety awareness and/or impaired physical function. The IDT recommends the resident for the Starlight program. The Staffing requirements include one aide for 8-10 residents, one assigned Starlight Program Coordinator, designated nurse assigned to care of resident, and aide staff responsible for the care needs of the residents. The Program ll Coordinator and Unit Manager are responsible for the management of the program, coordinating the screening and placement or removal of residents in the program, program development (planning, scheduling and monitoring), communication between the program, facility leadership and families, supervising and scheduling of all program staff, monitoring the delivery of services, collaborating with department heads, and Modeling excellent resident care. The Role of the Starlight aide includes: provide structured activities and companionship, provide meals and snacks, maintain cleanliness, monitor residents for safety, monitor for pain, assist with tilting, provide grooming nail and hair care, provide every 2 hour positioning, monitor behaviors, and document on ADL sheets. The aides are to be provided with a Walkie talkies to communicate with nursing staff outside of the room. The Starlight Schedule Form is a sample schedule for the aides to initiate with the residents. It is to be updated daily. The activities are to be selected based on each residents preference. The preferences are found in the resident's medical record. A review of the Starlight program manual revealed this form was not completed for each individual resident with their identified activity preferences and participation. The manual contained one form for random dates. The schedule form was not completed daily and was not signed by the person completing the form. The schedule stopped at 7:30 P.M., when in fact the program continued with the last aide until 9:00 P.M. The forms did not contain the daily names of the residents attending the program or staff working each day. The manual did not contain the names of the residents in the program. 13. An interview with the DON on 4/9/08 at 2:00 P.M. stated she could not provide the staffing in the Starlight Program because the Activities Director does the staffing. She stated the Activities Director was out of the building and did not know when she would return. At 2:40 P.M. the Activity Director arrived. She stated she does not do staffing for Starlight. She stated the staffing coordinator does the scheduling. She stated she gives the Starlight aides the schedule of activities for the day. She stated there were staffing issues in the facility and her activity aides are often pulled to cover the floor. 12 The surveyor walked with the Activity Director to the DON's office. The Activity Director stated to the DON she did not do staffing for Starlight. The DON stated she did, the Activity Director stated again that she didn't and left the room. 14. An interview with the Activities Director on 4/10/08 at 10:40 A.M. She reviewed the above Starlight policy, stated she is not providing supervision of the program. She stated she knew the policy stated that she was, but she was not the Starlight Program Coordinator. She stated the Staffing Coordinator staffs the Starlight program. She stated if an aide is absent then she tells the Staffing Coordinator and/or nursing since the aides fall under nursing. She stated she does not function as a Supervisor over the staff in the Starlight program. A review of the staff present during the resident #1's fall, she stated the aide listed for 8 hours was not present. She stated "I know she wasn't there, I interviewed her after the fall." She left the room to clarify the information. She was observed discussing the staffing with the Administrator. She returned and stated the aide was working but she was not in the room when the resident fell. She stated the aide had taken another resident to a room for toileting. She stated the Starlight aides take the residents to their room every 2 hours for toileting. She provided the staff sign in sheet for 3/27/08 which did not agree with the printed staffing provided by the facility. The form did not contain the signatures for any of the Starlights aides and did not include 2 of the 4 Starlight aides listed on the staffing mformation provided by the facility. The Activities Director stated the facility had no means of documenting daily the number of residents present in the Starlight program and the daily staffing of the Starlight program. She stated nursing was responsible for assessing the resident for the Starlight program and providing on-going monitoring. 15. On 4/10/08 at 12:50 P.M. an interview was conducted with the Staffing Coordinator. She stated she does all the staffing for the nurses and aides, including the Starlight Program. She stated she began the position 1-2 months ago. The staffing for the Starlight program was reviewed. She stated she did not know which residents were in the Starlight program. She stated she had not seen 13 a list of residents and did not know the total number of residents in the program. She stated the staffing should be 1 aide for 8 residents in the Starlight program. She stated she attempts to schedule at least 2 aides in the program. She stated when an aide calls in she attempts to obtain an aide from the floor, but they often refuse. She stated the residents in the Starlight program are residents which are combative or fell in the last 6 months. 16. Observation of the Starlight Program on 4/9/08 at 1:38 P.M. the Starlight residents are participating in a group activity with other residents outside the building. AI the residents are in wheelchairs, many with chair alarms. The wheelchairs do not contain identification of fall risk (star). Observation of the Starlight Program on 4/10/08 at 11:45 A.M., 5 residents were in the Activities room with 2 aides. All the residents were in wheelchairs, many with chair alarms. There was no falling stars on the wheelchairs to identify the high risk residents. A review of the list of the 13 residents provided by the facility was completed with the aides. They stated there were many residents that were not there. They stated that not all the residents come everyday. They stated some residents are in their rooms, in therapy, or with family. They are unsure the location of each resident in the Starlight program. They stated there is not a current mechanism in which they document which residents are attending the program, the times of attendance, and any care issues. An observation of the Starlight program on 4/10/08 at 6:10 P.M. there were 5 residents with 1 staff member. The program was located in the common area in front of the nurse station on Hall B. All the residents were cognitively impaired and in the wheelchair. One resident was self propelling themselves down the hallway. The resident had gone approximately 1/4 down the hallway when the Starlight aide went to catch them. The aide had her back to the other 4 residents. A second resident was extremely agitated and attempting to self propel themselves into the nurse station. A third resident was observed attempting to take off their lap belt. The atmosphere was one of chaos. The Activity Director arrived and asked the aide what did she normally do with the residents at night. The aide began to read the paper from a standing position, 14 she was told by the Director to sit down. The aide did not bring the residents to her prior to beginning to read. The Director stated she was not engaging the residents and this was not working as the residents continued to be agitated. During each of the observations of Starlight there was not a mechanism of communication with nursing staff, eg walkie talkies as per the policy. The aides were observed taking residents to their rooms or for other care needs leaving the program with one aide. A review of 7 of 7 (#1, 3,4,5,7,8,11) sampled residents in the Starlight program, their medical record revealed no assessment prior to placement in the program, the date of placement, and ongoing monitoring for effectiveness of the program. 17. A review of the facility's "Fall Risk Reduction and Management” clinical program stated residents which were identified as a high risk for falls a "star" symbol would be placed in an easily identified area near the resident e.g. bed, wheelchair, doorway etc. The Fall Action Team was to be notified if a resident experienced a fall. The "Fall Risk Identification and Plan of Care" form is to be updated when a fall occurs. The resident's fall risk factors are to be assessed which include: Limited orientation to own limitations, History of falls, altered elimination status, diuretics or medications with sedative effects, assistance required with transferring or ambulating. The Plan of Care is to be reviewed with interventions to minimize or eliminate falls. The Interdisciplinary Team works with the resident and family to provide education on expectations related to fall prevention and management strategies if a fall should occur. Post fall management includes appropriate resident care, evaluation and revision of existing interventions, and investigation into potential factors to determine areas of improvement. The policy stated the resident's medical record and circumstances surrounding the fall will be reviewed by the Fall Action Team by the next business day. A referral to is to be made to therapy after each fall. Therapy is to evaluate for skilled services, positioning or adaptive equipment, and restorative nursing services. The facility is to monitor and document the effectiveness of the interventions in prevention of recurrent falls. The policy stated the staff are to document in the medical record the following: date and time of incident, brief, factual and objective description of the incident, results of clinical findings, immediate interventions, resident location after occurrence, physician contact and family member contact. The staff are to evaluate and document on clinical condition once per shift for at least 72 hours post fall. This evaluation and documentation should include: vital signs, resident status, changes in cognition, physical status, pain, ability to participate in daily care and routine, response to changes in medications, treatments or interventions, results of lab/tests with notification of the physician, communication with the physician, family member and Interdisciplinary Team of any changes. 18. An observation of the resident #2's room on 4/11/08 at 10:15 A.M. it was noted the resident's room mate was on a low bed with mats. The room mate's name plate beside the door contained a symbol of 2 feet. The Activity Director was in the hallway pushing a resident. She was asked what the feet represented. She stated they are for fall precautions. The resident #2 review of medical record revealed a history of fall and fall precautions were care planned. The resident did not have any symbols near the bed to identify the resident as a fall risk. The resident had a symbol of a star on their door. The room mate did not have a star symbol on the door or on the bed as per policy. An observation of the Starlight residents, which were in a group religious activity on 4/11/08 at 10:20 A.M. The dining room area contained more -than 20 residents in wheelchairs, many with chair alarms. There were not any star or other symbols noted on the wheelchairs to identify which residents are fall risk. An interview with an aide present during the activity was asked how she identified which residents were high risk for falls. She stated they would have a guardian angle beside the door to their room. (This answer is not per the facility policy.) 10. The above constitutes a violation of § 400.102(1), Fla. Stat. (2007), and constitutes a widespread Class I deficiency pursuant to § 400.23(8)(a), Fla. Stat. (2007). lt. The Agency provided Respondent with a mandatory immediate correction date. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT IL RESPONDENT’S FACILITY FAILED TO IMPLEMENT AN EFFECTIVE QUALITY ASSESSMENT AND ASSURANCE PROCESS. § 400.147(1), Fla. Stat. (2007) WIDESPREAD CLASS I DEFICIENCY 12. The Agency re-alleges and incorporates paragraphs one (1) through five (13), as if fully set forth herein. 13. That Florida Law provides the following: 400.147 (1) 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: (c) Policies and procedures to implement the internal risk management and quality assurance program, which must include the investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents to residents : 14. That on April 9, 2008 through April 11, 2008, the Agency conducted three unannounced 17 complaint surveys at Respondent’s facility. The complaint allegations were confirmed. 15. Based on record review, observation, resident and staff interview the facility failed to ensure Administration effectively administered the facility to ensure the residents were able to maintain the highest practicable physical and psychosocial well-being through the implementation of an effective Fall and Starlight Program to provide increased supervision and safety to the most compromised and at risk population. The findings include: 1. During the survey of the facility 4/9/08 to 4/11/08 a systemic failure of the Fall and Starlight program was identified. The facility failed to implement the - policy and procedures for the Starlight and Fall programs to ensure the provision of Quality Nursing Care to meet the needs of the residents. The Administration failed to ensure the Quality Assurance program was effective and provided on- going monitoring to ensure the resident's care needs were being met. 16. Based on observation, record review and interview the facility failed to implement an effective Quality Assessment and Assurance process to ensure the provision of care and services were provided by staff per the facility's policy and procedures and Standard of Practice. The facility failed to identify, investigate, develop and implement an effective plan of action with an on-going process to monitor the effectiveness of the action plan. The findings include: 1. A review of the Fall Risk Reduction and Management clinical program stated the facility is to complete an analysis of facility fall data for quality improvement opportunities. The analysis is to be completed no less than monthly. Leadership review is to be done at the direction-of and through the risk management/quality improvement committee. Trending reports will include: _ time of fall, location in facility, type of fall, resident activity associated with fall. The trend data is collected to identify facility outcomes related to fall management. The Quality Improvement procedure includes the following: 1) Review of all internal reports related to falls. 2) Trend data to identify facility outcomes related to fall * management The trend data compares falls from week to week, potential reasons for repeat falls, and environmental data. 3) Evaluate information gathered from the "Fall Action Team: Fall Review Tool 4) Develop a systemic modifications to address identified fall risk issues. 5) Evaluate effectiveness of implemented modifications. 6) Provide ongoing staff education related to falls prevention. 2. A review of the fall log on 4/9/08 revealed 5 falls for April 2008 and 23 falls for March 2008. In an interview with the DON at 3:15 P.M. on 4/9/08, she gave the surveyor a fall log for February, which listed 19 falls. She stated the risk manager left the end of February and the DON could not find any logs for February. She stated she pulled the fall information from the computer. She stated they prepare a weekly report for corporate which includes falls and this is what she used to make a February fall log. She stated she did not have a fall log for December or January, She stated the computer only goes back to February 2008. She stated the falls were high in December and January and the facility had implemented an action plan. She reviewed the current measures in place to improve the falls at the facility which included the following: 1) the staff were to call her with each fall- she would assess for staff intervention, medications, labs etc, 2) the facility increased aide accountability 3) DON would decide if the resident was to go out. 4) call family/MD. 5) add alarms as needed. 6) each morning each fall is reviewed with fall action committee. 7) all falls get therapy screening. The DON provided Weekly Clinical Indicator reports which is reported to the corporate office. The report listed total numbers of falls each week. The report lists the last names of the residents, but did not list the 1st name, date of fall or any other information related to the fall. The facility had many residents with the same last name and there was no way to identify the resident. The report listed 26 falls for January 2008 and 40 falls for December 2007. 19 3. An interview with the DON on 4/11/08 at 10:30 A.M. stated all residents receive a therapy screen after a fall. A review of the therapy screen manual against the fall log revealed many discrepancies. In April 2008 there were listed 2 therapy screens. There was not a therapy screen for the other 3 residents which fell from April 1 to April 7. In March 2008 there were 23 falls listed but only 15 therapy evaluations. There were 2 therapy evaluations which did not correspond with the dates of the falls listed in the fall log. In February 2008 there were 19 falls listed with only 5 therapy evaluations. There was one therapy evaluation which did not correspond with the date of the fall listed in the log. Furthermore, the resident #14 had a therapy screen on 3/19/08 for a fall, which is not listed on the fall log. The resident #13 had a therapy screen on 3/17/08 for a fall which is not listed on the fall log. The resident #15 had a therapy screening on 3/10/08 for a fall which occurred on 3/8/08. The therapist documented the resident had fallen with a skin tear to the right knee and hematoma to the right posterior head. The resident was transferred to an acute hospital. There is no further information provided. The resident was not listed on the facility's fall log. In January 2008 there were 26 falls listed but only 18 therapy evaluations were completed. In December 2008 there were 40 falls listed but only 21 therapy evaluations were completed. Review of the therapy screens did not agree with the fall log which was often incomplete as to the name, date, and injury. A review of the screens revealed the following: - December 2007- 3 residents received head injuries from falls and 3 residents fell from their wheelchairs. -January 2008- 3 residents received an injury to their heads, 2 fell out of their wheelchair and 2 residents fell while attempting to find something to eat. -February 2008 - 4 residents fell out of their wheelchair and 1 received a head injury 20 -March 2008 - 1 resident received a head injury and 3 residents fell out of their wheelchairs. (Record review revealed a total of 3 resident's received head injuries #1, #4, #15) -April 2008 - 1 person fell out of their wheelchair 4. An interview was conducted with the DON on 4/10/08 at 3:30 P.M. Resident #1's fall of 3/27/08 was reviewed with her. The DON's investigation had indicated the resident fell out of the wheelchair sideways. The DON stated the Activity Aide, which actually saw the fall, stated the resident went rigid and it © looked like seizure activity immediately prior to the fall. The resident had no history of seizures. The DON was questioned on corrective measures put in place after the resident #1's fall on 3/27/08. She stated an in-service and coaching plan was provided to the Starlight aide #2 on safety and prevention of falls. The DON was questioned on the lack of nursing assessments including neurological assessment of the resident after the fall on 3/27/08. The DON confirmed the lack of nursing assessment. She stated she was aware of the lack of nursing care. She confirmed she had not implemented any interventions with the nursing staff which cared for the resident after the fall on 3/27/08. The medical record did not contain documentation to support the earlier interview with the DON which stated she had been notified of the fall with frequent phone calls to her and the ARNP over the weekend. She stated the first communication she received was from the RN on 3/30/08 at 9:10 P.M. The DON was asked who was the Starlight Coordinator. She stated that there had been confusion on who was responsible for the program. She stated after the surveyor questioned the program on 4/9/08 it had been clarified and now the Activity Director is responsible for the program. She confirmed previously there was not a supervisor responsible for the Starlight program. She was asked which staff member was responsible for ensuring the fall policy and procedure was implemented and followed. She stated it is a Risk Management responsibility and since she is the Risk Manager, it would be her responsibility. She stated the DON, QA, and RM position is too much for one person. 21 The DON provided a copy of the aforementioned coaching plan with aide #2. This plan is dated 3/26/08, which is the day before the fall of 3/27/08. The date of the coaching plan was brought to the attention of the DON on 4/10/08 at 3:30 P.M. The DON provided no explanation for the discrepancies in the date. The plan stated the aide failed to keep a resident safe. The plan does not specify the name of the resident which was neglected. The plan did not provide enough information to verify the plan is in relation to resident #1 and not-another resident. The coaching plan stated "Tag 226" "Neglect to keep resident safe in assigned group area." It does not list the specific resident or further details. The plan was to provide an in-service on resident safety. A copy of an in-service dated 3/27/08 was provided which stated the aide was in-serviced on safety and falls prevention. It is unclear how this was completed the same day as the fall, when the fall did not occur until 2:15 P.M. and the resident did not return to the facility until 7:45 P.M. 5. On 4/11/08 at 10:30 A.M. the DON produced an analysis of a time line of the events from 3/27/08 to 3/31/08 for the resident #1. The time line was noted to be inaccurate, such as, the RN assessment was listed as completed on 3/27/08, when in fact it was not completed until 3/30/08. The DON stated the resident was seen by the ARNP on 3/28/08. The last MD note in the medical record is dated 2/22/08. The DON stated she would have to locate the note. The DON stated the ARNP ordered labs on 3/28/08. The medical record contained an order for a CBC and BMP to be collected on 3/31/08. The order is signed by the LPN and does not contain the name of the physician/ARNP which ordered the lab, and if it was a verbal order or a telephone order. The ARNP did not write the order. The DON documented on 3/30/08 neuro checks were completed 1-3 times each shift. She could not provide documentation of these checks. She could not provide documentation of the Physician's notification of the resident's lack of urine output on 3/31/08. The DON's time line was not supported by the medical record. 6. On 4/9/08 at 2:00 P.M. the DON located an Action Plan dated November 19, 2007 with revision of December 14, 2007 to assist with the excessive amount of 22 falls identified by the facility. She stated she was unable to locate any further action plans. She stated the facility had implemented the plan which had decreased the amount of falls. She was unable to provide evidence the plan had been monitored for effectiveness with revision as needed. On 4/11/08 at 10:30 A.M. the DON reintroduced the Action Plan which she stated addressed the identified areas of a lack of resident supervision and staff accountability. She stated the facility was tracking and trending falls by shift and wing. The tracking did not include the resident's names or other information. The DON was unable to provide evidence of the assessment of the effectiveness of the action plan since it was implemented in December 2007. She was unable to provide evidence of the implementation of the process to ensure the methods used to collect fall data was accurate. She was unable to provide evidence of an on-going monitoring of falls to ensure the staff is following the facility's fall policy. 17. The above constitutes a violation of § 400.147(1)(c), Fla. Stat. (2007), and constitutes a widespread Class I deficiency pursuant to § 400.23 (8)(a), Fla. Stat. (2007). 18. The Agency provided Respondent with a mandatory immediate correction date. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $15,000.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to §§ 400.23(8)(a) and 400.102, Florida Statutes (2007). COUNT I 19. The Agency re-alleges and incorporates Counts I and II of this Complaint as if fully set forth herein. 20. Based upon Respondent’s two 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 ? 23 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 assi gn a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2007) commencing April 11, 2008. COUNT IV 21. The Agency re-alleges and incorporates Counts I, II and II of this Complaint as if fully set forth herein. ) 22. Respondent has been cited for two 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). 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). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I through Count IV; (B) Recommend an administrative fine against Respondent in the amount of $36,000 for Count I; II, and Iv; (C) Assess attorney’s fees and costs; and (D) Grant all other general and equitable relief allowed by law. 24 Respectfully submitted this bY aay of May, 2008. Mark Hinely, Esq. Fla. Bar. No. 48084 Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) 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. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8152 to Facility Administrator Thomas L. McDaniel, 3333 Capital Medical Blvd., Tallahassee, Florida 32308, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 8169 to Owner Capital Health Care Associates, 25 LLC, d/b/a Capital Healthcare Center, 10210 Highland Manor Drive, Suite 250, Tampa, FL 33610, and by U.S. Certified Mail, Retum Receipt No. 7004 2890 0000 5526 8176 to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301 on May ee 2008: ll Hinely, be | Copy furnished to: Barbara Alford, FOM 26 voog Menges "| [Be Miia DS ydjeooy wnjou 9NSeWOC . \DEKE, TS FRRMPQDA, WS, an, \or (rdnen snr TOAMPADA - key eGo}, 10) pessauppy elle “t *syuued coeds 3 uous ou UO JO ‘agardyeu ouy JO 4OBq Ou} 0} P/EO siuy YRRY “nod 0} peo auy UuNyas UD mM Jey OS ‘@sienas ayy UO SSAIPPe PU euweu anok yd -pailsep S| Aienyaq pase HF wey eyajduuoo osiy “6 pue ‘Z “L SWOL eye|dwog m ont] ~— molec. sseuppe Auonyep 20102 ‘SAA H 8A J} wy Woy yuaeyIp sseuppe LOAEP S| ‘a NOILOIS SIHL 3LITdINOO *HAGNAS AY3AITaG NO NOILOAS SIHL ILFTANOD ydisdey wim onsewiog pooz Aeniged ‘| [BE WOd Sd 25Te 9255 OOOO Ob?e HOoe , OpSt-W-20-S6SZOb (e0g eAxg) Lluened perouised “7 COOT] _ lew pensui C] esipueyoiewn 40} idyeoed] WNEH C1] peiaisiSeud (] wen sseidxa [] HEW PeuTED adh 9) e WEEE. 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" A O28 Ganeteacn Buh.| Smee, Boos Area, RL BROS 4. Restricted Delivery? (Extra Fee) Ol yes : 7004 2850 oo00 S5ebh 8244 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

Docket for Case No: 08-002678