OX YT STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRAT ; CESEP 23 PH li 21 AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2008008039 AHCA No.: 2008008040 Vv. Return Receipt Requested: 7008 0500 0002 0764 5475 DELTA HEALTH GROUP, INC. 7008 0500 0002 0764 5482 d/b/a BERKSHIRE MANOR, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter referred to as “AHCA”), by and through the undersigned counsel, and files this Administrative Complaint against Delta Health Group, Inc. d/b/a Berkshire Manor (hereinafter “Berkshire Manor”), pursuant to Chapter 400, Part II, and Section 120.60, Florida Statutes (2007), and alleges: NATURE OF THE ACTIONS 1. This is an action to impose an administrative fine of $1,000.00 pursuant to Section 400.23(8), Florida Statutes (2007), for the protection of the public health, safety and welfare. 2. This is an action to impose a Conditional Licensure status to Berkshire Manor, pursuant to Section 400.23(7) (b), Florida Statutes (2007). JURISDICTION AND VENUE 3. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2007), and Chapter 28- 106, Florida Administrative Code. 4, Venue lays in Miami-Dade County, pursuant to Section 400.121(1) (e), Florida Statutes (2007), and Rule 28-106.207, Florida Administrative Code. PARTIES 5. AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing nursing: homes, pursuant to Chapter 400, Part II, Florida Statutes, (2007), and Chapter 59A-4 Florida Administrative Code. 6. Berkshire Manor is a 245-bed nursing home facility located at 1255 NE 135°" Street, North Miami, Florida 33161. Berkshire Manor is licensed as a skilled nursing facility; license number SNF1334096; with certificate 15276, effective 12/04/2007 through 04/30/2008 for the Conditional License. The Conditional License changed to Standard with certificate number 15277, effective 01/23/2008 through 04/30/2008. Berkshire Manor was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I BERKSHIRE MANOR FAILED TO ENSURE THAT PHYSICIANS ORDERS WERE FOLLOWED FOR SOME RESIDENTS Rule 59A-4.107(5), Florida Administrative Code (FOLLOW PHYSICIANS ORDERS) REPEATED CLASS III VIOLATION 7. AHCA re-alleges and incorporates paragraphs (1) through (6) as if fully set forth herein. 8. During the annual licensure survey conducted from 9/18/06 through 9/21/06 and based on observation, record review, and interview it was determined that the facility failed to meet professional standards of quality by not following physician’s order as evidence by the use of tube feeding, Catapres, vitamin liquid, nitro patch, and oxygen (02). This affected 4 residents (Resident #3, #4, #14, and #18) of 27 sampled residents, and 1 (Resident #27) of 5 random residents. 9. Professional Standard of Care is defined in Chapter 766.102 as, "the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers." 10. The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill .based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administrations of medications and treatments a prescribed or authorized by a duly licensed practitioner "practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirmed 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. 11. An observation of Resident #4’ room on 09/18/06 at 11:38 a.m. revealed bolus feeding bag hung and label with a date of 9/18/06, name of the feeding (Nutren Glytrol 250 cc) and times of when feeding should be administered 12 am, 4 am, 4 pm, and 8 pm. Further review of label on bolus feeding bag, revealed that feeding was signed as given for 12 a.m. and 4 a.m. (a) A record review of MAR for September 2006 revealed Nutren Glytrol 250 cc per gastronomy tube every 4 hours 12 am, 4 am, 4 pm, and 8 pm. (b) An observation on 9/18/06 at 3:46 pm, 4:40 pm Resident #4 tube feeding was not running. (c) An interview with the Licensed Practical Nurse on 9/18/06 at 5:12 pm revealed resident did not receive his/her feeding at 4 pm because the facility would prefer he/she eat dinner by mouth. However he/she will receive his feeding at 6 pm. (d) An observation of Resident #4 on 9/18/06 at 5:48 pm he/she is still waiting for dinner, no bolus feeding administered. (e) At 5:51 pm on 9/18/06 the dinner cart was observed coming down the hall of C-wing. An interview with the Certified Nursing Assistant (CNA) stated Resident #4’s tray is on the second cart. (f£) Resident #4 was observed on 9/18/06 at 6:02 pm receiving his/her dinner tray, CNA provided set help and resident feed him/herself. (g) An interview with the LPN on 9/18/06 at 6:08 am confirmed resident #4 did not receive 4 pm bolus feeding because he/she will get it at 6 pm. However, he/she is eating dinner right know, and after dinner his/her feeding will be administered. (h) An interview with the DON on 9/19/06 at 3:57 pm indicated that Nutren Glytrol 250 cc feeding will be discontinued because resident is eating better. (i) An interview with the Director of Nursing (DON) on 9/20/06 at 9:42 am confirmed that feeding was not wa administered as prescribe by physician 12a, 4a, 4p, and 8 pm, instead it was administered at 6:20 pm. In addition, the DON had the LPN who signed the MAR to add a late entry that bolus feeding was administered at 6:20 pm instead of 4 pm as prescribed by the physician. (j) A record review of Resident #4 MAR reveals Catapres-TTS 3 patch apply 1 patch topically every week at 9 a.m. In addition, to a PRN order of Catapres 0.1 via tube every 8 hrs as needed for blood pressure (BP) over 160/100. Further record review of resident #4 MAR reveals he/she was administered Catapres-TT3 patch on 9/3/06, and Catapres PRN via peg on 9/4/06 with BP of 140/100. (k) An interview with LPN on 9/18/06 at 5:12 pm confirmed the PRN dose of Catapres should not have been administered. (1) An interview with another LPN on 9/19/06 at 10:32 am revealed that he/she was a floater and did not sign off the PRN dose of Catapres but confirms it should not have been given because BP was not over 160/100. (m) An interview with the DON on 9/20/06 at 5:37 pm with the Nurse Consultant, Administrator and other surveyor present confirmed that resident should not have received PRN order of Catapres because his/her BP was not over 160/100 and if the LPN was unsure of the order he/she should of called the physician to clarify the order. 12. A record review of Resident #14 September 2006 MAR reveals vitamin liquid 15 milliliter (mil) via gastronomy tube (g-tube) will be discontinued on August 22, 2006. However, on the September 2006 MAR reveals the medication was administered up until September 10, 2006. (a) A vecord review of physician order dated 8/22/06 at 5:06 pm revealed vitamin liquid was discontinued. (b) An interview with the DON on 9/19/06 at 10:01 am, after reviewing the resident MAR and physician’s order confirmed that vitamin liquid was discontinued on 8/22/06 and should not have been administered until September 10, 2006. 13. An observation of Resident #18 on 9/20/06 at 9:35 am, 12:28 pm, 12:32 p.m. revealed Oxygen (02) infusing at 2.5 liter (L) via nasal canal. (a) An interview with the Licensed Practical Nurse (LPN) on 9/20/06 with DON present at 1:36 pm confirmed that the 02 was infusing 2.5 L via nasal canal and physician order stated 2 L. (b) During an observation on 9/20/06 at 1:38 pm with the DON, O02 was infusing at 2 L via nasal canal after surveyor intervention. 14. An observation during the medication pass on 9/19/06 at approximately 8:20 am revealed that the nurse was looking for a Nitro patch to place on Resident #27; she could not find any in the resident's medication draw. After giving the resident his medications the nurse informed the resident that she would come back and give the resident his Nitro patch. The resident informed the nurse he already had gotten the Nitro patch on this morning. The nurse locked at the Nitro patch and it was dated 9/19/06 at 6 am. (a) Review of the Medication Administration Record (MAR) revealed the order was for the Nitro Patch to be applied at 8 am and removed at 10 pm. (b) An interview with the Director of Nursing on 9/19/06 at approximately 9:15 am revealed that she confirmed the night nurse did not follow the physician's order by applying the Nitro patch on at the wrong time. 15. Resident #3 was admitted to the facility on 8/25/06 with the diagnosis of traumatic brain injury. (a) An observation of resident #3 on 9/18/06 at 11:40 am, 4:05 pm, 4:30 pm, and 5:25 pm noted that she/he was wearing an oxygen mask set at 2 LPM (liters per minute). (b) Observation of Resident #3 on 9/19/06 at 9:25 am, 10:40 am, and 12:15 pm revealed that the resident was wearing an oxygen mask with the concentrator set at 2 liters per minute. (c) Resident #3's record had a physician's order dated 8/28/06 for oxygen via mask, however there was no documentation of an ordered oxygen flow rate. After the surveyor had inquired about where the order oxygen flow rate was documented, a clarification order was written on 9/19/06 specifying the oxygen flow rate at two liters per minute continuously. (d) A review of nursing notes in Resident #3's clinical record revealed various nursing notes, such as 8/26/06, 8/27/06, 8/29/06, 8/30/06, 8/31/06, 9/03/06, 9/04/06, 9/08/06, 9/13/06, 9/16/06, and 9/17/06 indicating the oxygen had been used or continuously used and was set at 2 LPM without a documented physician's order. 16. During the re-licensure survey conducted on 12/04/07 and based on record review, observation, interview and review of the facility's policy, the facility failed to assure that services provided by the facility met professional standards of quality for the following: i) One (Resident #1) of 14 sampled residents received a medication that the physician ordered as a discontinued medication; 2) One (Resident #3) of 14 sampled residents did not receive medications, accuchecks and nutritional supplements that the physician ordered. 17. Professional Standard of Care is defined in Chapter . 766.102 as, “the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers." 18. The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as "the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administrations of medications and treatments as prescribed or authorized by a duly licensed practitioner; "practice of practical nursing" as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or informed 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. 19. Resident #1's record included but was not limited to diagnoses of gastrostomy, encephalopathy, congestive heart failure and cognitive deficits. The current December 2007 physician's orders did not include orders for the medication Seroquel. The verbal order dated 11/21/07 indicated that the Seroquel was discontinued. The November 2007 medication administration record (MAR) noted that the Seroquel had a handwritten entry that indicated the Seroquel was discontinued as of 11/21/07. (a) The December 2007 MAR had revealed: 1) a handwritten entry "D/C 11/21/07" was written inside the section that said "Seroquel 100mg tablet by mouth at bedtime", and 2) the Seroquel 100mg tablet was administered on 12/01/07 and 12/02/07 at 9:00 pm, although this medication had been discontinued. There were no written orders to administer the Seroquel on 12/01/07 and 12/02/07. '(b) An observation on 12/04/07 at 11:45 am of the medication cart, which had Resident #1's medications, revealed that there was an opened box of Seroquel with 45 tablets in it for Resident #1. The Seroquel box's label was delivered 11/13/07 with 60 tablets from the pharmacy. The opened box of Seroquel was not labeled as discontinued and was present among the current medications for Resident #1. (c) An interview with the Assistant Director of Nursing and two nurses on 12/04/07 at 11:55 am confirmed that after reviewing Resident #1's orders the Seroquel was ordered discontinued as of 11/21/07. An interview with the Director of Nursing on 12/04/07 at 12:00 pm. revealed discontinued medications should be removed from the medication cart. 20. A review of the facility policy entitled Medication Administration General Guidelines revealed "18. Prior to administration, the medication and dosage schedule on the patient's MAR/TAR is compared to the medication label....If the medication is discontinued...remove the medication for proper disposal." This policy was not followed because the medication Seroquel was discontinued and it was not removed for proper disposal. 21. An interview on 12/04/07 at 12:35 pm with the psychiatrist who was helping to oversee Resident #1's care revealed the resident has been stable and there was no negative interaction although the resident was administered the discontinued Seroquel on 12/01/07 and 12/02/07. 22. Resident #3's clinical record included but was not limited to diagnoses of atrial .fibrillation, diabetes mellitus, renal insufficiency, congestive heart failure, and chronic obstructive pulmonary disease. The current December 2007 physician's orders and medication administration record (MAR) revealed the following orders: (a) Accucheck with sliding scale coverage two times a day scheduled at 6:00 am and 4:30 pm. {b) Novolin 70/30 inject 16 (sixteen) units subcutaneously every morning scheduled at 6:30 am. (ec) Novolin 70/30 inject 7 (seven) units subcutaneously every evening scheduled at 4:30 pm. (d). Coumadin 6 mg tablet by mouth daily on empty stomach scheduled at 6:00 am. (e) Aricept 10 mg tablet by mouth daily at bedtime for diagnosis of Dementia scheduled at 9:00 pm. (£) Lipitor 10 mg tablet by mouth at bedtime diagnosis hyperlipidemia scheduled at 9:00 pm. (g) Remeron (Mirtazepine) 45 mg tablet by mouth at bedtime for diagnosis depression scheduled at 9:00 pm. (h) Med Pass 2.0, 60 cc three times a day scheduled at 9:00 am, 1:00 pm and 5:00 pm. 23. Review of Resident #3's current December 2007 MAR on 12/04/07 12:30 pm revealed the following: (a) No accucheck conducted for 6:00 am on 12/01/07; No accucheck conducted for 4:30 pm on 12/01/07 and 12/02/07. (b) No administration. of Novolin 70/30 16 units for 6:30 am on 12/01/07; No Novolin 70/30 7 unit insulin for 4:30 ‘pm on 12/01/07 and 12/02/07. (c) No administration of Aricept 10 mg tablet at bedtime at 9:00 pm on 12/01/07 and 12/02/07. {d) No administration of Lipitor 10 mg tablet at bedtime at 9:00 pm on 12/01/07 and 12/02/07. (e) No administration of Remeron 45 mg tablet at bedtime at 9:00 pm on 12/01/07 and 12/02/07. (f£) No administration of Med Pass 2.0 scheduled at 5:00 pm on 12/01/07, 12/02/07 and 12/03/07. (g) No administration of Coumadin 6 mg at 6:00 am at 12/01/07. (h) There was no documentation on the MAR or the clinical record, which explained why the medications, nutritional supplement, and accuchecks were not administered as ordered. 24. An interview with the Director of Nursing on 12/04/07 at 12:40 pm confirmed that Resident #3's MAR did not have documentation, which explained why the medications and accuchecks were not administered as ordered. 25. An interview on 12/04/07 at 2:40 pm with the nurse who cared for Resident #3 on 12/01/07 and 12/02/07 during the 13 (3-11) evening shift revealed she/he insisted the resident got the ordered medications and accuchecks, but could not prove that the resident got the medications and accuchecks when the surveyor asked the nurse. 26. An observation on 12/04/07 at 2:45 pm of Resident #3's medication boxes revealed the following: (a) Box of Aricept 10 mg with 20 tablets counted. Its label indicated the pharmacy dispensed 30 tablets on 11/21/07. (b) Box of Remeron 45 mg with 18 tablets counted. Its label indicated the pharmacy dispensed 30 tablets on 11/13/07. (c) Box of Coumadin 6 mg with 22 tablets counted. Its label indicated the pharmacy dispensed 30 tablets on 11/14/07. (d) Box of Lipitor 10 mg with 26 tablets counted. Its label indicated the pharmacy dispensed 30 tablets on 11/25/07. (e) Vial of Novolin 70/30 insulin. Its label indicated it was opened on 11/20/07. (£) An interview on 12/04/07 at 3:00 pm with the administrative nursing staff and the nurse revealed the boxes of medications are not dated when they are opened. 27. A review of the facility's policy entitled Medication Administration General Guidelines revealed "9. Only the licensed or legally authorized personnel who prepare a medication may administer it. This individual record the administration on the patients' MAR/TAR after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/TAR to ascertain that all necessary doses were administered and all administered doses were documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications." The nurse(s) did not follow the facility's policy for medication administration. This is a repeat deficiency from the the 9/21/06 re-licensure survey. 28. Based on the foregoing, Berkshire Manor violated Rule 59A-4.107{5), Florida Administrative Code, classified as an isolated repeated Class III deficiency pursuant to Section 400.23(8)(c), Florida Statutes, which carries, in this case, an assessed fine of $1,000.00 for an isolated deficiency. This violation also gives rise to a conditional licensure status pursuant to Section 400.23(7) (b). DISPLAY OF LICENSE Pursuant to Section 400.23(7)(e), Florida Statutes, Berkshire Manor shall post the 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. The Conditional and Standard Licenses are attached hereto as Exhibit “A” and “B”. CLAIM FOR RELIEF WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief: A. Make factual and legal findings in favor of the Agency on Count I. B. Assess an administrative fine of $1,000.00 against Berkshire Manor on Count I for an isolated deficiency. c. Assess and assign a conditional license status to Berkshire Manor in accordance with Section 400.23(7) (b), Florida Statutes. D. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, Florida Statutes (2007). Specific options for administrative action are set out in the attached Election of Rights and explained in the attached Explanation of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency for Health Care Administration, Agency Clerk, 2727 Mahan Drive, Mail Stop #3, Tallahassee, Florida 32308, telephone (850) 922- 5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST FOR A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. ia Lawton-Russell Assistant General Counsel Agency for Health Care Administration Spokane Building, Suite 103 8350 NW 52™ Terrace Miami, Florida 33166 Copies furnished to: Field Office Manager Agency for Health Care Administration 8355 NW 537¢ Street, First.Floor Miami, Florida 33166 (Interoffice Mail) Finance and Accounting Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14 Tallahassee, Florida 32308 (Interoffice Mail) Nursing Home Unit Program Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 (Interoffice Mail) di

Docket for Case No: 08-004762