STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, C eUN% | AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. Case Nos. 2008007558 (Fine) 2008007559 (CL) NINTH STREET HEALTH CARE ASSOCIATES, LLC d/b/a HERITAGE HEALTHCARE AND REHABILITATION 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 NINTH STREET HEALTH CARE ASSOCIATES, LLC d/b/a HERITAGE HEALTHCARE AND REHABILITATION CENTER (hereinafter “Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) pursuant to Section 400.23(8)(b), Florida Statutes (2007), based upon one (1) Class Il deficiency and assign conditional licensure status beginning on April 25, 2008, and ending on June 3, 2008, pursuant to Section 400.23(7)(b), Florida Statutes (2007). The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. JURISDICTION AND VENUE 1. The Court has jurisdiction over the subject matter pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). 2. The Agency has jurisdiction over the Respondent pursuant to Section 20.42, Chapter 120, and Chapter 400, Part II, Florida Statutes (2007). 3, Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. PARTIES 4. The Agency is the regulatory authority responsible for the licensure of skilled nursing facilities and the enforcement of all applicable federal and state statutes, regulations and rules governing skilled nursing facilities pursuant to Chapter 400, Part II, Florida Statutes (2007) and Chapter 59A-4, Florida Administrative Code. The Agency is authorized to deny, suspend, or revoke a license, and impose administrative fines pursuant to Sections 400.121, and 400.23, Florida Statutes (2007); assign a conditional license pursuant to Section 400.23 (7), Florida Statutes (2007); and assess costs related to the investigation and prosecution of this case pursuant to Section 400.121, Florida Statutes (2007). ) 5. Respondent operates a 97-bed nursing home, located at 777 Ninth Street North, Naples, Florida 34102, and is licensed as a skilled nursing facility, license number 1224096. 6. Respondent was at all times material hereto, a licensed skilled nursing facility under the licensing authority of the Agency, and was required to comply with ali applicable state rules, regulations and statutes. COUNT I The Respondent Failed To Ensure Physician’s Orders Were Followed In Violation Of Rule 59A-4.107(5), Florida Administrative Code 7. The Agency re-alleges and incorporates by reference paragraphs one (1) through six (6). 8. 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. Rule 59A-4.107(5), Florida Administrative Code. 9. On or about April 21, 2008 through April 25, 2008 the Agency conducted an Annual Survey at Respondent’s facility. 10. Based on observation, record review, and interview, the facility failed to ensure physician's orders were followed for seven (7) of twenty (20) active sampled residents, Resident number one (1), Resident number four (4), Resident number six (6), Resident number eight (8), Resident number nine (9), Resident number thirteen (13), and Resident number fifteen (15). This failure resulted in harm to Resident number eight (8) requiring immediate physician intervention and the resident missed therapy, and Resident number four (4) was placed at risk for more than minimal harm due to a missed laboratory test to monitor medication levels. Physician orders were also not followed for a stool culture to determine an infectious organism for Resident number thirteen (13); for an air mattress to prevent skin breakdown for Resident number eight (8); for blood pressure and heart rate to be taken prior to blood pressure medication being administered as ordered for Resident number six (6) and Resident number fifteen (15) being administered the wrong blood pressure medication; for a missed lab and tuberculin skin tests for Resident number nine (9) and Resident number one (1) who received a treatment without a physician's order. 11. | Arecord review revealed Resident number eight (8) was admitted on Monday, March 31, 2008 with a diagnosis of Congestive Heart Failure, High Blood Pressure, Stroke and Atrial Fibrillation (a rapid irregular heart rate). 12. Physician's orders on admission included a Pro Thromin/International Normalized Ratio lab test (determines how quickly the blood clots) to be completed on Thursday, April 3, 2008 and every Monday and Thursday thereafter. Resident number eight (8) had been taking Coumadin, a medication to thin the blood, in the hospital. A further review of the clinical record revealed the test wes not completed on April 3, 2008 as ordered by the physician. The Pro Thromin/International Normalized Ratio was drawn on the next Monday, April 7, 2008 and the result was 7.4 (normal range 2 - 3.5), placing Resident number eight (8) at risk for hemorrhage. Resident number eight (8) missed therapy due to this critically high lab value and was administered an injection of Vitamin K as ordered by the physician to reverse the effect of the . Coumadin. An interview with the attending physician on April 22, 2008 at 3:50 p.m. revealed the International Normalized Ratio of 7.4 was a “little bit high." 13. The drug information handbook for Nursing, 2007 lists Coumadin as a drug with a heightened risk of causing significant patient harm when used in error. The drug information handbook for nursing further lists hemorrhage as the most serious risk of Coumadin therapy. 14. Aninterview with the unit manager on April 22, 2008 at 3:45 p.m. revealed the facility receives admitting orders from the final summary when the resident is discharged from the hospital. The attending physician is then contacted to confirm, add or change the orders. The admitting orders are then transcribed directly onto a physician order sheet to review and sign for approval. A further review of the final summary revealed Resident number eight’s (8) International Normalized Ratio was 4.2 (high) upon discharge from the hospital and he/she had blood in his/her urine, therefore recommending the International Normalized Ratio be completed on April 2, 2008. An interview with the attending physician on April 22, 2008 at 3:50 p.m. revealed the hospital order to have Resident number eight’s (8) International Normalized Ratio drawn on Wednesday should have been a priority over the facility's protocol of Mondays and Thursdays and the lab should have been drawn on April 2, 2008. 15. A complete review of the record failed to reveal a Pro Thromin/International Normalized Ratio result for Wednesday, April 2, 2008 or Thursday April 3, 2008. 16. An interview with the unit manager on April 22, 2008 at 3:45 p.m. revealed the specimen for the Pro Thromin/International Normalized Ratio test was not drawn on April 2, 2008 or April 3, 2008. The unit manager further revealed she had no explanation as to the reason why the specimens were not collected. 17. A further review of the telephone orders for Resident number eight (8) revealed the physician ordered an air mattress for the resident's bed on April 1, 2008. Air mattresses decrease the risk of developing pressure sores. An observation of Resident number eight’s (8) bed on April 21, 2008 and April 22, 2008 revealed no air mattress. On April 23, 2008 at 10:00 a.m. the unit manager confirmed Resident number eight (8) never received an air mattress. An interview with the nurse consultant on April 23, 2008 at 10:50 a.m. revealed Resident number eight (8) had refused to have an air mattress on his/her bed; however, there is no documentation to support this. 18. Resident number four (4) was admitted to the facility on August 14, 2007 with multiple diagnoses, including Seizure Disorder. 19. Aclinical record review revealed the physician ordered a Dilantin level lab draw on March 7, 2008 after an increase in Resident number four’s (4) seizure medication. A review of the Treatment Administration Record for March, 2008 revealed the order had been initialed as being done by the nurse; however, there was no evidence of any results in the clinical record. This was confirmed by the corporate nurse. An interview with Resident number four’s (4) spouse on April 21, 2008 at 10:00 a.m. and on April 22, 2008 at 5:00 p.m. revealed Resident number four’s (4) spouse stays with Resident number four (4) throughout the day to make sure his/her Dilantin is administered. Resident number four’s (4) spouse reported Resident number four (4) has had seizures for fifteen (15) years. 20. Acontinued clinical record review revealed Resident number four (4) has a long history of seizures and the physician has ordered the resident to have a Dilantin level drawn monthly. Resident number four’s (4) history includes constant monitoring of the Dilantin level due to the constant variation in therapeutic levels. Dilantin is a medication that must be kept at a specific range to prevent seizures. The therapeutic Dilantin level in the blood is ten (10) to twenty (20). A further clinical record review revealed the following: a. October 25, 2007 - Dilantin level 21.6 (high). b. December 7, 2007 - Resident had seizure lasting 40 seconds. c. December 10, 2007 - Dilantin level 9.8 (low). d. December 29, 2007 - Resident had seizure while outside with her husband. e. January 8, 2008 - Dilantin level 21.8 (high). f. January 23, 2008 - Dilantin level 4.2 (low). The physician increased the Dilantin. g. February 26, 2008 - Dilantin level 8.5 (low). The physician increased the Dilantin. h. March 7, 2008 - Missed Dilantin lab draw. i. April 7, 2008 - Dilantin level 10.8. 21. Acclinical record review for Resident number six (6) revealed a diagnosis of high blood pressure and due to high readings the physician made several recent changes in his/her medication. A current signed physician’s order reveals the nurse is to obtain a blood pressure or heart rate prior to administering Lopressor, a medication that lowers blood pressure and heart rate. If Resident number six’s (6) pulse is below 60 or systolic (top number) blood pressure is below 100, the nurse is not to administer the medication. A review of the current Medication Administration Record for April revealed there were no consistent blood pressure or heart rate values documented at the time of medication administration. The last recorded blood pressure and pulse result for April was on the fifth. Resident number six’s (6) blood pressure was 118/58 and pulse was 60. 22. Aclinical record review conducted for Resident number fifteen (15) revealed a physician telephone order dated April 22, 2008 to begin administering Lisinopril 5 mg daily, a medication to lower blood pressure, and to discontinue Altace 2.5 mg, a medication to lower blood pressure. A review of the April 2008 Medication Administration Record revealed Resident number fifteen (15) had received the Altace 2.5 mg instead of the Lisinopril as ordered for two (2) days. This was verified in the presence of the unit manager at 4:25 p.m. on April 24, 2008 after medication reconciliation was completed. The unit manager further commented that it was a medication error and an incident report would have to be completed. 23. A current signed physician order for Resident number nine (9) revealed the resident was to have a Tuberculin Skin Test (a test for tuberculosis) and a Basal Metabolic Panel (lab work for several blood tests) in March and September. A further clinical record review revealed it was not documented as being done in March and no results were on Resident number nine’s (9) chart. An interview with the medical record clerk and staff nurse on April 23, 2008 at 11:50 a.m. confirmed the skin test and lab work were not completed in March 2008. 24. A review of the record for Resident number thirteen (13) on April 24, 2008 revealed the resident was re-admitted to the facility on November 2, 2007. A review of the nurse's notes dated November 12, 2007 revealed Resident number thirteen (13) was treated with Flagy!, an antibiotic used for cases of infectious diarrhea. A physician's order, dated November 12, 2007, was obtained for a stool culture to determine the presence of Clostridium Difficile (C-Diff), the bacteria that can cause infectious diarrhea. A review of the laboratory results for Resident number thirteen (13) on April 24, 2008 revealed there was no result for the stool culture ordered on November 12, 2007. 25. Anobservation of Resident number one (1) several times during the survey including April 22, 2008 at 2:00 p.m. revealed he/she was wearing flesh colored compression stockings while in a. wheelchair. A clinical record review revealed no current physician’s order for compression stockings. This was confirmed by the unit manger on April 24, 2008 at 3:00 p.m. 26. The agency determined that this deficient practice has compromised the resident's ability to maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. The Agency cited the Respondent for a Class II deficiency as set forth in Section 400.23(8)(b), Florida Statutes (2007). 25. A Class II deficiency is subject to a civil penalty of $2,500 for an isolated deficiency, $5,000 for a patterned deficiency, and $7,500 for a widespread deficiency. A fine shall be levied notwithstanding the correction of the deficiency. 26. Based upon the above findings, the Respondent’s actions, inactions or conduct constituted a Class I isolated deficiency pursuant to Section 400.23(8)(b), Florida Statutes (2007). 27. The Agency provided Respondent with a mandatory correction date of May 25, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Sections 400.23(8)(b) and 400.102, Florida Statutes (2007). COUNT I Assignment Of Conditional Licensure Status Pursuant To Section 400.23(7)(b), Florida Statutes (2007) 28. The Agency re-alleges and incorporates by reference the allegations in Count I. 29. The Agency is authorized to assign a conditional license status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2007). 30. Due to the presence of one (1) Class II deficiency, the Respondent was not in substantial compliance at the time of the survey with criteria established under Chapter 400, Part II, Florida Statutes (2007), and the rules adopted by the Agency. 31. The Agency assigned the Respondent conditional licensure status with an action effective date of April 25, 2008. The original certificate for the conditional license is attached as Exhibit A and is incorporated by reference. 32. The Agency assigned the Respondent standard licensure status with an action effective date of June 3, 2008. The original certificate for the standard license is attached as Exhibit B and is incorporated by reference. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the Respondent conditional licensure status for the period beginning April 25, 2008 and ending on June 3, 2008 pursuant to Section 400.23(7)(b), Florida Statutes (2007). CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully requests the Court to enter a final order granting the following relief against the Respondent as follows: 1. Make findings of fact and conclusions of law in favor of the Agency on Count I and Count II. 2. Impose an administrative fine against the Respondent in the amount of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00). 3. Assign a conditional license to the Respondent for the period beginning April 25, 2008, and ending June 3, 2008. 4. Assess costs related to the investigation and prosecution of this case. 5. Enter any other relief that this Court deems just and appropriate. Respectfully submitted this agMdday of @, iguat , 2008. a J “fe Assistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3203 NOTICE RESPONDENT IS NOTIFIED THAT IT/HE/SHE HAS A RIGHT TO REQUEST AN ADMINISTRATIVE HEARING PURSUANT TO SECTIONS 120.569 AND 120.57, FLORIDA STATUTES. THE RESPONDENT IS FURTHER NOTIFIED THAT IT/HE/SHE 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 AND DELIVERED TO THE ATTENTION OF: THE AGENCY CLERK, AGENCY FOR HEALTH CARE ADMINISTRATION, 2727 MAHAN DRIVE, BLDG #3, MS #3, TALLAHASSEE, FLORIDA 32308; TELEPHONE (850) 922-5873. THE RESPONDENT IS FURTHER NOTIFIED THAT IF A REQUEST FOR HEARING IS NOT RECEIVED BY THE AGENCY FOR HEALTH CARE ADMINISTRATION WITHIN TWENTY-ONE (21) DAYS OF THE RECEIPT OF THIS ADMINISTRATIVE COMPLAINT, A FINAL ORDER WILL BE ENTERED BY THE AGENCY. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the Administrative Complaint and Election of Rights form were served to: Michele Bain, Administrator, Ninth Street Health Care Associates, LLC d/b/a Heritage Healthcare and Rehabilitation Center, 777 Ninth Street North, Naples, Florida 34102 by U.S. Certified Mail, Return Receipt No. 7007 1490 0004 1620 6834 and to Corporation Service Company, Registered Agent for Ninth Street Health Care Associates, LLC d/b/a Heritage Healthcare and Rehabilitation Center, 1201 Hays Street, Tallahassee, Florida 32301, by U.S. Certified Mail, Return Receipt No. 7007 1490 0004 1620 6827, on this GB, dayof Qugusat- , 2008. ton Bricy J “ge Assistant General Counsel Florida Bar No. 0355712 Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 (239) 338-3203 Copies furnished to: Michele Bain, Administrator Ninth Street Health Care Associates, LLC d/b/a/ Heritage Healthcare and Rehabilitation Center 777 Ninth Street North Naples, Florida 34102 (U.S. Certified Mail) “| Mary Daley Jacobs Assistant General Counsel Agency for Health Care Administration Office of the General Counsel 2295 Victoria Avenue, Room 346C Fort Myers, Florida 33901 Ninth Street Health Care Associates, LLC d/b/a/ Heritage Healthcare and Rehabilitation Center 1201 Hays Street Tallahassee, Florida 32301 (U.S. Certified Mail) (Interoffice Mail) Corporation Service Company Harold Williams Registered Agent for Field Office Manager Agency for Health Care Administration 2295 Victoria Avenue, Room 340A Fort Myers, Florida 33901 (Interoffice Mail) Exhibit A Original Certificate of Conditional License For Ninth Street Health Care Associates, LLC d/b/a Heritage Healthcare and Rehabilitation Center Certificate No. 15252 License No. SNF1224096

Docket for Case No: 08-004581