STATE OF FLORIDA 2p, é & AGENCY FOR HEALTH CARE ADMINISTRATION “7 yy" O On, *4 9, _ SO Yer y 3 g STATE OF FLORIDA, OX s (Ss | : AE. Meritage: . AGENCY FOR HEALTH CARE | Cg Ye ADMINISTRATION, . Petitioner, vs. Case No. 2008007534 "RIVERWOOD NURSING CENTER, Respondent : / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against RIVERWOOD NURSING CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57, Florida Statutes (2007), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $3,000 against the Respondent, based upon being cited for one uncorrected, isolated Class III deficiency. JURISDICTION AND VENUE | 1. _. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2007). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of nursing homes and enforcement of applicable federal regulations, state statutes and rules governing skilled nursing © facilities pursuant to the Omnibus Reconciliation Act of 1987, Title IV, Subtitle C (as amended), Chapter 400, Part Il, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4, Respondent operates a 119-bed nursing home, located at 40 Acme Street, Jacksonville, Florida 32211, and is licensed as a nursing home license number 1508095. 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 FAILED TO DEVELOP A PLAN OF CARE TO ASSESS, REASSESS AND MONITOR FULL SIDE RAILS, 59A-4.109(2), Florida Administrative Code (2007) ISOLATED CLASS II 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 that the facility is responsible to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and social well-being. The care plan must be completed within 7 days after completion of the resident assessment, 59A- 4.109(2), Florida Administrative Code (2007). 8. That on April 14, 2008 to April 18, 2008 an unannounced licensure survey was conducted at the Respondent’s facility. 9. Based upon observation, clinical record review and staff interview, the facility failed to develop and revise care plans to reflect the current level of function for five of thirty-four sampled residents, Residents #86, #134, #102, #117, and #98. Failure to develop a plan of care and revise care plans to reflect the current level of function for each resident could result in staff not providing the appropriate care and services to meet the resident at the point of their need. The findings include: 1. Interview with the Unit manager on 4/ 16/08 at 10:00 am regarding Resident #86 stated that they are monitoring for psychotropic medications, Seroquel, Depakote and Ativan PRN. The current plan of care for psychotropic medications stated that the resident was at risk for signs and systems of side effects related to psychotropic medications Depakote and Zoloft. Seroquel was not listed on the plan of care. 2. A review of the current plan of care for Resident #134 revealed two areas that did not reflect the resident’s current status and may not have reflected the resident's needs on admission. The initial plan for cognition dated 1/22/08 revealed short and long term memory loss and impaired decision making ability. The resident was able to voice needs to staff. The goal was that the resident "will continue to voice needs thru next review" which was noted as 4/22/08. One of the approaches was to provide mental stimulation, and provide one on one visits regularly. There were no specific activity interventions noted for what would provide mental stimulation. There was no evidence that the facility had recognized the resident's past interest in the religious community. The Activities Progress notes, admission note dated 1/13/08, noted the resident as "a wanderer and that the resident liked to walk. Will place the resident on the BB "busy buddy" list and do activities on the go". The Progress notes quarterly note on 4/9/08 identified that the resident was a "busy buddy" with no indication on a plan of care as to what the "busy buddy” activities would be. The communication plan of care dated 1/22/08 noted the resident's speech to be clear and had no problem voicing concerns, Interview with South wing nursing staff on 4/15/08 at 1:45 PM noted that the resident can state a few words, but the resident cannot tell you what they would want to do and the resident's speech was not clear. Interview with a family member on 4/14/08 at 12:45 PM revealed that the family member cannot understand the resident. . 3. Review of the record for Resident #117 revealed this resident had lost a significant amount of weight. The resident weighed 235 pounds when he/she was admitted on 11/1/07. In January, 2008, the resident weighed 222 pounds and in April, 2008 the resident weighed 209. Review of the Registered Dietitian's notes dated 4/2/08 revealed this resident had lost weight and recommended extra portions of meat at each meal. The resident was also ordered to receive 2 scoops of protein powder three times each day relative to low albumin levels. Review of the Physician Order Sheet (POS) dated 4/1/08 revealed this resident was on a No Added Salt (NAS) diet with extra portions of meat and 2 scoops of protein powder three times each day. Review of the care plans dated 2/20/08 with a target date of 6/20/08 revealed no nutritional care plan for this resident. Interview with the Minimum Data Set (MDS) Coordinator at 2:45 PM on 4/17/08 confirmed that the facility had failed to develop a nutritional care plan for this resident. Review of the record revealed Resident #117 was ordered Prolixin, a psychoactive medication, on 3/5/08 for behaviors exhibited. Review of the psychoactive care plan dated 2/20/08 revealed care plan had not been revised to reflect the use of Prolixin. 4. Resident #98 was observed independently eating a plate of pureed food at lunch on 4/14/08 from 12:29'p.m. to 1:15 p.m. The same resident was again observed on 4/15/08 at 8:30 a.m. independently eating a plate of pureed food during breakfast. A review of the clinical record revealed that there was a physician's order, dated 3/31/08, that read that Resident #98 was not to receive tube feeding if he/she ate a meal (breakfast, lunch and dinner); however, if the resident choked or did not eat a meal, commence with tube feeding. The order was noted by nursing on 4/5/08. The care plans for activities of daily living and another for nutrition, both dated 4/10/08, read that Resident #98 was totally dependent for eating and was to receive both tube feedings and pureed meals. Interventions included: tube feed flow rate was 65 ce per hour via g-tube for 15 hours per day; the tube feeding time was from 6 a.m. 3 p.m.; provide pureed diet with nectar thick liquids. Neither care plan mentioned the conditions that the resident was to receive the tube feeding or puteed food. Interview with the M.D.S. (Minimum Data Set) Coordinator on 4/17/08 at 12:06 p.m. confirmed that she had not carried over the physician's order for the resident to receive either the tube feeding or the pureed meals if certain conditions had not been met to the care plan. The same interview revealed that the M.D.S. coordinator was not aware that ~ Resident #98 was no longer totally dependent on staff with eating pureed meals by mouth. 5. Observation of Resident #102 on 4/14/08 at 1:15 p.m. revealed that he/she was lying in bed, resting comfortably. The tube feed was running at 250 ml per hour of Nutren 1.5 with Fiber running at 250 ce per hour and water flushes at 100 ce every 8 hours. The bed was elevated 30° degrees. A bag of water was hung from the pole as well as a bag of formula. At 12:42 p.m. on 4/16/08 Rt. #102's eyes were closed. The tube feed was running at 250 cc per hour and water flushes were set at 100 ml every 8 hours. Resident #102 had a care plan for nutrition that had not been updated to reflect resident's current tube feeding formula, rate and fluid needs. The care plan was last updated on ; oy 15/08 to reflect an increase in bolus feedings of Pro-balance at 7 cans a day. A physician's order, dated 3/28/08, changed the tube feeding formula and the administration rate to 250 cc per hour of Nutren 1.5 with Fiber, 8 bolus feedings each day. Water flushes were changed from 200 cc every shift to 100 cc every shift. The resident's next scheduled review would have been in June 2008. 10. The above constitutes a violation of 59A-4.109(2), Florida Administrative Code (2007), and constitutes an isolated Class III deficiency pursuant to § 400.23(8)(c), Fla. Stat. (2007). 11, The Agency provided Respondent with a mandatory correction date of May 18,.2008. 12. That on May 21, 2008, the Agency conducted an unannounced revisit from the recertification survey of April 18, 2008, at Respondent’s facility. 13. Based on record review and interview the facility failed to develop a plan of care to assess, reassess and monitor full side rails for 5 of 12 sampled residents, Residents #29, #53, #97, #1 32, and #133, who were at risk of side rail entrapment. Failure to develop a plan of care for side rails can result in resident being at risk for entrapment. The findings include: . 1. Resident #132 was newly admitted on 5/6/08 with one of the diagnoses being Huntington Chorea. Upon admission the Resident was assessed by the facility for the use of side rails and side rail entrapment risk. The side rail entrapment assessment resulted in the Resident being at risk. The initial plan of care for the Resident did not include interventions to guide the staff on the use of side rails and/or the monitoring of the Resident at risk of entrapment. 2. Resident #133 was newly admitted on 5/13/2008 with diagnoses of Alzheimer's Dementia and Encephalopathy. Upon admission the Resident was assessed by the facility for the use of side rails and side rail entrapment risk. The side rail entrapment assessment resulted in the Resident being at risk. The initial plan of care for the Resident did not include interventions to guide the staff on the use of side rails and/or the monitoring of the Resident at risk for entrapment. 3. Review of record for Resident #29 revealed that the Resident was assessed for entrapment due to the use of side rails. The result of the assessment was that the Resident was at risk for entrapment. Review of the Resident's plan of care revealed that there was a care plan for falls. There were no interventions to guide the staff on the use of side rails and/or the monitoring of the Resident at risk of entrapment. 4. Review of record for Resident #53 revealed that the Resident was assessed for entrapment due to the use of side rails. The result of the assessment was that the Resident was at risk for entrapment. Review of the Resident's plan of care revealed that there was a care plan for falls. There were no interventions to guide the staff on the use of side rails and/or the monitoring of the Resident at risk of entrapment. 5. Review of record for Resident #97 revealed that the Resident was assessed for entrapment due to the use of side rails. The result of the assessment was the the Resident was at risk for entrapment. Review of the Resident's plan of care revealed that there was a care plan for falls. There were no interventions to guide the staff on the use of side rails and/or the monitoring of the Resident at risk of entrapment. 6. On 5/21/2008 at 12:15 PM during an interview with Director of Nursing (DON), these findings were reviewed. The DON stated that the facility did not develop a plan of care for side rai] use and proper monitoring of the resident for entrapment safety post the assessment for Resident #29, #53, #97, #132, and #133. 14. The above constitutes a violation of 59A-4.109(2), Florida Administrative Code (2007), and constitutes an isolated Class III deficiency pursuant to § 400.23(8)(c), Fla. Stat. (2007). 15. The Agency provided Respondent with a mandatory correction date of June 20, 2008. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $3,000 against Respondent, a nursing home in the State of F lorida, pursuant to §§ 400.23(8)(c) and 59A-4.109(2), Florida Administrative Code (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 J; (B) Recommend an administrative fine against Respondent in the amount of $3,000 for Count I; (C) Grant all other general and equitable relief allowed by law. Respectfully submitted this dh Siay of August, 2008. - “ } i Yio} Shaddrick A. Haston, Esq. Fla. Bar. No. 31067 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 1160 0003 3739 4578 to Facility Administrator Terry K Carpenter, 1839 Turnberry Court, Green Cove Springs, Florida 32043, by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 4585 to Owner Riverwood Nursing Center LLC 40 Acme Street, Jacksonville, Florida 32211, and by U.S. Certified Mail, Return Receipt No. 7004 1160 0003 3739 4592 to Registered Agent John F. Gilroy, II, PA, 1435 East Piedmont Drive, Suite 215, Tallahassee, Florida 32308 on August US boos: +} Shaddrick A. Haston, Esq. Copy furnished to: Nancy K. 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Docket for Case No: 08-005157