From: To: Eidetik 11/17/2008 16:11 #34) P.002/035 aan “fe r, “Sf an SS STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION ' STATE OF FLORIDA AGENCY FOR 0 \e lo 2 pe) 7 HEALTH CARE ADMINISTRATION, Petitioner, Case No. 2008011634 vs. - AICC, INC., d/b/a AMELIA ISLAND CARE 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 AICC, INC., d/b/a Amelia Island Care Center (hereinafter Respondent), pursuant to Section 120.569, and 120.57, Florida Statutes, (2008), and alleges: NATURE OF THE ACTION This is an action to revoke Respondent’s license to operate an intermediate care facility for developmentally disabled persons in the State of Florida pursuant to §408.815, Florida Statutes (2008), and to impose an administrative fine of ten thousand dollars ($10,000) based upon two (2) State Class I deficiencies pursuant to §§ 400.967(3)(a) and 400.969(1), Florida Statutes (2008). , JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 20.42, 120.60, and Chapters 408, Part II, and 400, Part VII, Florida Statutes (2008). 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. EXHIBIT PoA From: To:Eidetik 11/17/2008 16:11 #341 P.003/035 PARTIES 3. The Agency is the regulatory authority responsible for licensure of intermediate care facilities and enforcement of all applicable state statutes and rules governing intermediate care facilities pursuant to the Chapters 408, Part J, and 400, Part VIIL, Florida Statutes, respectively. 4. Respondent operates a 70-bed intermediate care facility located at 2700 Atlantic Avenue, Fernandina Beach, FL 32034, and at all times material hereto was licensed as an intermediate care facility, license number 4010096. 5. Respondent was at all times material hereto a licensed facility under the licensing authority of the. Agency, and was required to comply with all applicable rules and statutes. . COUNT I 6. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. That pursuant to Florida law, “Intermediate care facility for the developmentally - disabled" means a residential facility licensed and certified in accordance with state law, and certified by the Federal Government, pursuant to the Social Security Act, as a provider of Medicaid services to persons with developmental disabilities. §400.960(8), Florida Statutes (2008). As a Condition of Participation of Medicaid services, a facility must provide clients with _ nursing services in accordance with their needs. 42 C.F.R. 483.460(c). 8. That Florida law provides the following: "Practice of professional nursing" means 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: 1. The observation, assessment, pursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of From: To: Eidetik 11/17/2008 16:12 #341 P.004/035 others; 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized by the laws of this state to prescribe such medications and treatments; 3. The supervision and teaching of other personnel in the theory and performance of any of the above acts. “Practice of practical nursing” means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(a) and (b), Fla. Stat. (2008). 9. That pursuant to Florida law, the applicant must demonstrate that sufficient numbers of staff, qualified by training or experience, will be employed to properly care for the type and number of residents who will reside in the facility. §400.962(4), Florida Statutes (2008). 10. That pursuant to Florida law, in addition to the requirements of part II of chapter 408, and except as provided in s. 400.967(3), a violation of any provision of this part, part II of chapter 408, or applicable rules is punishable by payment of an administrative or civil penaity not to exceed $5,000. §400.969(1), Florida Statutes (2008). 11. That pursuant to Florida Jaw, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. Unless the amount ’ or aggregate limitation of the fine is prescribed by authorizing statutes or applicable rules, the agency may establish criteria by rule for the amount or aggregate limitation of administrative fines applicable to this part, authorizing statutes, and applicable rules. Each day of violation constitutes a separate violation and is subject to a separate fine. For fines imposed by final order of the agency and not subject to further appeal, the violator shall pay the fine plus interest at the From: To:Eidetik 11/17/2008 16:12 #341 P.005/035 rate specified in s. 55.03 for each day beyond the date set by the agency for payment of the fine. §408.813, Florida Statutes (2008). 12. That on September 8-11, 2008, the Agency conducted an unannounced Licensure Survey of the Respondent’s facility. 13. ‘That based upon observations, the review of records and interview, Respondent failed to provide clients with nursing services in order to meet the client needs where Respondent failed to adequately monitor and intervene for medical conditions and to provide nursing services, qualified by training and experience, to meet a client’s needs where persistent complaints of chest pain and discomfort were not addressed for a client. 14. That Petitioner’s representative reviewed Respondent’s records regarding client number eleven (11) during the survey and noted as follows: a. The client was admitted to the facility on July 6, 1978; d. The client’s primary diagnosis was profound mental retardation and secondary diagnoses of cerebral palsy, status post right hip dislocation, history of chronic anemia, degenerative changes on the left hip, contracture of upper and lower extremities, seborrheic dermatitis, gastroesphogeal reflux disease (GERD), and history of fracture of the 4th metacarpal of the right hand; c. The current Annual Staffing Medical Evaluation was completed March 1, 2007 and revealed no changes in medical diagnoses, noted weight at one hundred twenty-one (121) pounds and the client’s height of five foot one and one-half inches; d. . The March 1, 2007 Annual Staffing Medical Evaluation reflected the client’s prognosis as good, and there were no life threatening conditions noted; From: To: Eidetik 11/17/2008 16:12 #341 P.006/035 e. A April 10, 2007 Habilitation Evaluation revealed the client was non-ambulatory, but used a motorized wheelchair effectively and further documented that the client’s speech was difficult to understand, but those that were familiar with the client were able to understand the client needs and requests. f. Medical record reflects that from March 1 through 31, 2008, Physician Orders included Zantac 300 milligrams (mg) tablet to be given by mouth everyday at bedtime for the diagnosis of GERD; Gaviscon 15 ml liquid to be given as needed every 5 hours for indigestion and Trazadone Hydrochloride. g. The Trazadone Hydrochloride was initially prescribed for the diagnosis of sleep on February 2, 2007 and the order was to be administered 25 mg every day at bedtime; h. ; A physician’s order of March 6, 2008 increased the Trazadone Hydrochloride to 50 mg every day at bedtime; i. A Side Effects Report regarding the Trazadone Hydrochloride included the instruction to " notify the doctor promptly if the following symptoms developed: chest pain, rapid heart rate, shortness of breath, difficulty urinating, blood in the urine, nightmares, and uncoordinated movements;"” j. The client’s July 2007 through March 2008 medication administration record was reviewed which reflected the following administrations of Gaviscon 15 ml: a. On July 8, 2007 at 8:00 a.m. with no documented complaint listed; b. On July 18, 2007 at 7:20 PM for complaint of indigestion; c. Once in August 2007 for complaint of indigestion but no date recorded; d. On February 2, 2008 at 11:30 am. due to indigestion; From: : To:Eidetik 11/17/2008 16:12 #341 P.007/035 e. On March 30, 3008 at 6:25 a.m. for complaint of discomfort in chest; £ On March 3, 2008 with no time documented for the complaint of chest discomfort. k. The nurses log report recorded the following for March 30, 2008: a. Inthe morning, the client complained of pain in chest and the nurse obtained the client's vital signs and listed them as blood pressure 111/73, pulse 59, respirations 24; Gaviscon 15 milliliters (ml) was administered by mouth with the notation the " Director of Nursing (DON) will observe;" b. At 7:45 a.m. recorded is that the director of nursing telephoned the nurse to check on the client and was informed by the nurse that the client had voiced no complaints up to the present time; c. At 9:20 a.m. recorded is that the client complained of chest pain, calmly and with no immediate distress noted; d. Gaviscon 15 cc was administered and the vital on assessment at 9:20 a.m. was listed as pulse 74, blood pressure 100/74, and respirations as 22; e. At 9:45 a.m. the nurses log report recorded that the nurse was informed that the client had refused breakfast and was currently attending a church service in the facility. The nurse was informed by a visitor attending the church service that the client was complaining of chest pain and informed the visitor she was aware of the client's complaints. The nurse entered the church service and told the client to go to A Wing in order to be put to bed; From: To:Eidetik 11/17/2008 16:12 #341 P.008/035 f. The nurse log recorded that the client went to A Wing and asked staff for assistance to bed and requested the use of the urinal; 5 At 10:23 am. the nurses log report recorded that the nurse was notified by staff that something was wrong with the client and when the nurse arrived at the client's, room the client had no pulse or respirations and was cyanotic. ) h. At 10:27 a.m. the nurses log report recorded that cardiopulmonary resuscitation (CPR) was started and continued until rescue workers . artived at 10:30 a.m. and assumed care of the client; i. At 10:35 a.m. the nurses log report recorded that client had expired and she would contact all proper individuals and agencies. 1. Anentry in the nurse’s log report of March 31, 2008 at 6:15 am. recorded . "regarding client number eleven (11) a nurse’s late entry documenting that she had contacted the director of nursing at 6:15 a.m. on March 30, 2008, reported the vital signs as stated in the notes, and was told by the director of nursing to elevate the head of the bed and give Gaviscon as ordered by the physician and to observe. m. Petitioner’s representative reviewed Respondent’s investigation conducted following the death of client number eleven (11) and noted an undated written statement completed and signed by the director of nursing which recorded as follows: a. That she had been contacted on March 30, 2008 at 6:15 a.m. by the nurse caring for client number eleven (11) regarding the client's complaint of some chest pain/discomfort; From: To:Eidetik 11/17/2008 16:13 #341 P.009/035 b. The nurse told her that the vital signs and color of client number eleven (11) were good and the client did not look to be in any distress; c. The nurse verified the history of GERD of client number eleven (11) and would make sure to elevate the head of the client’s bed, and would medicate the client with Gaviscon as needed for GERD symptoms; d. The director of nursing noted that the nurse was instructed not to call : her back and do what she needed to do for client number eleven (11); e. The director of nursing noted that she called the facility on March 30, 2008 at 7:45 a.m. and spoke with nurse on duty regarding the status of client number eleven (11) and was advised that the client was up and about in wheelchair and had no further complaints. That Respondent’s records regarding the death of client number eleven (11) include an annotation that the director of nursing spoke with the client's physician via telephone on March 31, 2008 at 12:55 p.m. and was advised the client’s cause of death to be "Sudden Cardiac Death”. 15. That Petitioner’s representative interviewed Respondent’s director of nursing on September 11, 2008 at 2:20 p.m., with Respondent’s administrator present, who indicated as follows: a That when she was contacted initially on March 30, 2008, she told staff to monitor client number eleven (11); When she called back at 7:45 a.m. on March 30, 2008, she was advised by the nurse that client number eleven (11) did not have any more complaints; She was not contacted when client number eleven (11) was medicated at 9:20 a.m. on March 30, 2008; From: To: Eidetik 41/17/2008 16:13 #341 P.010/035 d. That Respondent’s Licensed Practical Nurses (LPNs) do not assess clients, but are aware of the usual status of the clients; e. That clients are usually sent out, meaning sent to an emergency room, for anything out of the ordinary or the doctor is notified. 16. That Petitioner’s representative interviewed Respondent’s administrator on September 11, 2008 at 2:20 p.m., with Respondent’s director of nursing present, who indicated as follows: a. That client number eleven (11) was complaining of chest pain during the morning medication pass and she felt the nurse was busy passing medication and did not feel the client’s complaints of continued chest pain were a priority over getting the medications administered; b. That she had conducted an undocumented conversation with the nurse caring for client number eleven (11) on March 30, 2008 during the 7am - 3pm shift . indicating that complaints of chest pains should take priority over passing medications. 17. That both Respondent’s director of nursing and administrator denied that any changes to the facility’s nursing policies, procedures or protocols regarding client care had been implemented after the events involving client number eleven (11) and the Respondent’s review of the incident. 18. That Respondent has undertaken care of services for persons in its residential facility licensed and certified in accordance with state law, and certified by the Federal Government, pursuant to the Social Security Act, as a provider of Medicaid services to persons with developmental disabilities. See, §400.960(8), Florida Statutes (2008). Asa Condition of Participation of Medicaid services, a facility must provide clients with nursing services in accordance with their needs. 42 C.F.R. 483.460(c). From: To:Eidetik 11/17/2008 16:13 #341 P.011/035 19. That Respondent, as an intermediate care facility for the developmentally disabled, is required to provide nursing services in accordance with client needs, and to provide sufficient staff, qualified by training or experience, to properly care for the type and number of clients accepted by the facility. See, §§400.960(8) and 400.962(4), Fla. Stat. (2008), and 42 C.F.R. 483.460(c). 20. Respondent intentionally or negligently failed to provide adequate nursing services or staff, qualified by training or experience, to properly care for client number eleven(11), including, but not limited to, Respondent’s failure to: a. Perform nursing diagnosis where the client exhibited consistent complaints of chest pain and discomfort; b. Assess and evaluate the client after the administration of medications and determine the efficacy of such medications; c. Monitor the client where consistent complaints of chest pain and discomfort existed; d. Obtain from a physician or emergency services treatment orders based upon assessments, nursing diagnosis, and continued client complaints of chest pain; ec, Provide treatment for continued complaints of chest pain where prescribed interventions proved ineffective. f. Ensure that licensed practical nurses are appropriately supervised to assure care quality. 21. That the above reflect Respondent’s violation of the provisions of law controlling intermediate care facilities for the developmentally disabled. 22. That the Agency determined that the above constitutes grounds for the imposition of a Class I deficiency in that it presents an imminent danger to the residents or guests of the facility 10 From: To:Eidetik 11/17/2008 16:13 #341 P.012/035 or a substantial probability that death or serious physical or emotional harm would result therefore. 23. That the Agency cited the Respondent for a Class I violation in accordance with § 400.967(3)(a), Florida Statutes (2008). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an intermediate care facility in the State of Florida, pursuant to §§ 400.967(3)(a) and 400.969(1), Florida Statutes (2008). COUNT II 24. That on September 8-11, 2008, the Agency conducted an unannounced Licensure Survey of the Respondent’s facility. 25. That pursuant to Florida law, "Intermediate care facility for the developmentally disabled" means a residential facility licensed and certified in accordance with state law, and certified by the Federal Government, pursuant to the Social Security Act, as a provider of Medicaid services to persons with developmental disabilities. §400.960(8), Florida Statutes (2008). As a Condition of Participation of Medicaid services, a facility must provide clients with nursing services in accordance with their needs. 42 C.F.R. 483.460(c). , 26. That Florida law provides the following: “‘Practice of practical nursing’ means the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual’s educational preparation and experience in nursing.” § 464.003(b), Fla. Stat. (2008). From: To: Eidetik 11/17/2008 16:13 #341 P.013/035 27. That pursuant to Florida law, the applicant must demonstrate that sufficient numbers of staff, qualified by training or experience, will be employed to properly care for the type and number of residents who will reside in the facility. §400.962(4), Florida Statutes (2008). 28. That pursuant to Florida law, in addition to the requirements of part IT of chapter 408, and except as provided in s. 400.967(3), a violation of any provision of this part, part II of chapter 408, or applicable rules is punishable by payment of an administrative or civil penalty not to exceed $5,000. §400.969(1), Florida Statutes (2008). 29. That pursuant to Florida law, as a penalty for any violation of this part, authorizing statutes, or applicable rules, the agency may impose an administrative fine. Unless the amount or aggregate limitation of the fine is prescribed by authorizing statutes or applicable rules, the agency may establish criteria by rule for the amount or aggregate limitation of administrative fines applicable to this part, authorizing statutes, and applicable rules. Each day of violation constitutes a separate violation and is subject to a separate fine. For fines imposed by final order of the agency and not subject to further appeal, the violator shall pay the fine plus interest at the rate specified in s. 55.03 for each day beyond the date set by the agency for payment of the fine. §408.813, Florida Statutes (2008). — 30. ‘That based upon observations, the review of records and interview, Respondent failed to provide clients with nursing services in order to meet the client needs where Respondent failed to adequately monitor and intervene for medical conditions and to provide nursing services, qualified by training and experience, to meet a client’s need resulting in the presence of untreated open wounds for a client. 31. The Petitioner’s representative reviewed Respondent’s records regarding client number five (5) and noted as follows: From: To:Eidetik 11/17/2008 16:13 #341 P.014/035 The client was admitted to the facility April 17, 1974 with the primary diagnosis of mild mental retardation and secondary diagnoses of cerebral palsy, behavior disorder, intermittent anemia, due to excessive gum bleeding, chronic subluxation of the shoulders, hypothyroidism and seborrheic dermatitis; Physician orders for September 1 through 30, 2008 included, but were not limited to, Duoderm patch as needed for the diagnosis of open area with special instructions to apply Duoderm to open area on right heel; The start date of this order was October 26, 2006; An order for Bacitracin Ointment as needed for the diagnosis of skin integrity with special instructions of minor skin injury, clean with soap and water hada start date of March 31, 1994. 32. The Petitioner’s representative was notified on September 9, 2008 at 3:00 p.m. by Respondent’s staff member that the client was in bed because the client had a sore bottom, stating that the "bottom has broken out again”. 33. ‘That on September 9, 2008 at 5:45 p.m., with the client's permission, Petitioner’s representative observed the peri-care of client number five (5) and noted as follows: a. There was an area of dark colored excoriated skin on the client ' s right buttock that was approximately eight (8) inches in length by four (4) inches wide; A small Duoderm dressing approximately two by two (2x2) inches was revealed near the inner aspect of the right buttock adjacent to the anus and another two by two (2x2) inch Duoderm dressing was revealed at the bottom of the right buttock at the gluteal fold that partially covered an open wound; The Duoderm dressings were not.dated or initialed regarding when the dressings were placed; 13 From: To:Eidetik 11/17/2008 16:14 #341 P.015/035 d. The direct care staff providing the care revealed the open areas were "pretty deep”. 34. That Petitioner’s representative left the room of client number five (5) and interviewed Respondent’s director of nursing regarding client number five (5) during which the director of nursing indicated as follows: a. That she was just advised of the open wounds of client number five (5) "just this morning;” b. The client was "scheduled to be seen by the doctor this Thursday,” c. The Duodenm was put on the wounds "this morning”. 35. That Petitioner’s representative noted that the medical record of client number five (5) included a physician’s order dated September 9, 2008 at 3:15 p.m. with special instructions to apply Duoderm as needed to buttock area for the diagnosis of “Open Area.” 36. That Petitioner’s representative interviewed, on September 10, 2008 at 10:30 a.m., the nurse at the off-site Day Program (329 Place) regarding her knowledge of the open wounds of client number five (5) who indicated that she was not aware that the client had any wounds and that when a client had any wounds, the facility advised 329 Place. 37. That Petitioner’s representative, with the permission of client number five (5) observed the staff nurse at 329 Place examine the wounds of the client on September 10, 2008 at 10:40 a.m. and noted as follows: a. ‘When the-client's underwear was removed, the Duoderm was in the client's underwear; Db. There were two open areas on the right buttocks; c. Client number five (5) was rolled onto the left side; From: To: Eidetik 11/17/2008 16:14 #341 P.016/035 d. The open area located at the upper inner aspect of the right buttock near the anus was approximately the size of a 25 cent coin/2 centimeters (cm), and the depth ‘was approximately 1/4 inch/0.64 cm. The edges were jagged. The tissue was pink/red and moist with a granular appearance. No odor or drainage was noted; e. The open wound at the bottom of the right buttock/gluteal fold was approximately 1 inch in width at the center of the visible portion of the wound, The length of the wound could not be determined as it started at the center of the lower right buttock and extended past the scrotum, but approximately 3 1/2 - 4 inches of the wound could be seen. The depth of the wound could not be determined; f. The client expressed discomfort/pain when the nurse attempted to move the client's leg and scrotum to further examine the wound; 2. The nurse did not attempt to continue the wound assessment due to the client's pain; h. The tissue was pink/red, moist with a granular appearance with some bleeding noted. The edges were jagged. No odor was detected. No drainage was detected other than the small amount of bleeding; i Following peri-care, the client was dressed and returned to the wheelchair. 38. That Petitioner’s representative interviewed, on September 10, 2008, the licensed practical nurse who had cared for client number five (5) who indicated that she had cared for the client for many years and that the client had a history of open sores on the right buttock and the facility "just puts duoderm on it and it heals right up." 39. Petitioner’s representative reviewed Respondent’s Nurses Notes Section of the medical record of client number five (5) and noted the following from the nurse log report during the month of July: From: To: Eidetik 14/17/2008 16:14 #341 P.017/035 On July 4, 2008 at 11:10 p.m. - an old area on right buttocks with large amount of bleeding noted this shift, area cleaned and medicated cream applied to area, RLA’s (Residential Life Assistants) are to keep client on their side and off of buttocks as much as possible during the day, out of their wheelchair. On July 5, 2008 at 5:48 a.m. - notes revealed a small amount of blood was noted to buttocks area. Area cleaned with soap and water and Bacitracin applied. On July 5, 2008 at 10:03 a.m. - notes revealed no bleeding noted at this particular time. "Small open area that has reopened on buttock. Bacitracin ointment applied at this time. Will continue to monitor until resolved." On July 6, 2008 at 3:56 a.m. - notes revealed area on buttocks "continues to bleed, clean area and applied medicated cream as ordered by physician, turned client to their side and will continue to observe." On July 6, 2008 at 9:24 a.m. - notes revealed the client noted to have no bleeding from. buttock area at this present time. "Bacitracin ointment applied to open area. Will continue to monitor. Off buttock after meals.” On July 6, 2008 at 7:46 PM - notes revealed the client was in bed and bacitracin ointment applied to non-bleeding open area. On July 7, 2008 at 2:17 a.m. - notes revealed bleeding noted coming from buttock area, cleaned area and applied Bacitracin ointment. "Will continue to keep off of buttocks and open to air while in bed, will continue to observe." On July 7, 2008 at 10:22 a.m. - notes revealed no bleeding noted from area thus far. "Client denies any complaints at this particular time.” 16 From: To: Eidetik 11/17/2008 16:14 #341 P.018/035 i. On July 7, 2008 at 10:02 PM - notes revealed no bleeding noted to area on buttocks. "No complaint of pain or discomfort. Bacitracin ointment applied. Will continue to monitor." j. On July 8, 2008 at 6:29 a.m. - notes revealed no bleeding this shift. k. On July 9, 2008 at 6:17 a.m. - notes revealed issue resolved regarding buttock discomfort. 40. _ Petitioner’s representative reviewed Respondent’s Nurses Notes Section of the medical record of client number five (5) and noted the following from the nurse log report during the month of August: . a On August 8, 2008 at 4:23 PM - notes revealed open area noted to right inner buttock 1 and 1/2 inch in length and | inch in width. "Small amount of bleeding noted. Area cleaned with soap and water, Bacitracin ointment applied. Positioned on side to relieve pressure. Will monitor.” db. On August 9, 2008 at 3:04 a.m. - notes revealed Bacitracin ointment applied to all areas on buttocks some drainage noted at the site, turned client on side off of area, will continue to observe. c. On August 9, 2008 at 10:05 - notes reveal two open areas noted to buttocks. "One to coccyx area, the other to right lower cheek area. Coccyx has scant amount of bleeding. Bacitratin ointment to areas. Client in bed after breakfast to relieve pressure on areas." d. On August 9, 2008 at 9:49 PM - notes revealed at 9:00 PM "scant bleeding noted from both open areas to buttocks, treatment as ordered. Client crying out when From: To: Eidetik 11/17/2008 16:14 #341 P.019/035 ointment applied, indicating discomfort to area, positioned to avoid pressure to area, will continue to monitor." €. On August 10, 2008 at 4:06 a.m. - notes revealed on side at this time, “applied treatment as ordered by physician, small amount of red drainage noted from site, no complaint of pain or discomfort noted at this time, will continue to observe." f. On August 10, 2008 at 9:49 PM - notes revealed " client lying on side at this time to avoid pressure to buttocks, treatment as ordered applied at 9:00 PM, no bleeding from open areas noted this shift, will continue to monitor.” g. On August 11, 2008 at 2:56 a.m. - notes revealed "Duoderm applied to open areas on buttocks, bleeding noted from areas at this time, client on side at this time, will continue to observe this shift.” h. On August 10, 2008 at 9:45 a.m. - notes revealed "Duoderm remains intact at this time to buttock open area. Will continue to monitor until completely resolved." i. On August 11, 2008 at 11:21 PM - notes revealed "Duoderm intact to buttock. Wiil continue to monitor." j. On August 12, 2008 at 5:41 a.m. - notes revealed " treatment as ordered to open areas on buttocks 5:00 a.m., left open to air. Client positioned to avoid pressure to area, no drainage noted, no signs or symptoms of infection. Will monitor." k. On August 12, 2008 at 10:28 a.m. - notes revealed "scant bleeding noted to inner buttocks area. Area cleansed with warm water and cloth, Bacitracin ointment and Duoderm applied. No signs or symptoms of infection noted, monitoring continues.” 18 To:Eidetik 11/17/2008 16:15 #341 P.020/035 On August 12, 2008 at 10:14 PM - notes revealed “no bleeding noted this shift. Treatment as ordered." _ On August 13, 2008 at 5:50 a.m. ~ notes revealed "Bacitracin ointment to buttock area. On August 14, 2008 at 3:24 a.m. - notes revealed "Duoderm applied to open area on buttocks drainage noted coming from areas at this time, will continue to observe." On August 14, 2008 at 10:41 a.m. - notes revealed "Duoderm remains intact. No drainage has been noted." On August 14, 2008 at 10:43 PM - notes revealed "Duoderm intact." On August 15, 2008 at 5:48 a.m. - notes revealed reapplied "Duoderm to buttock this shift, drainage noted from two areas, will continue to observe." On August 15, 2008 at 10:20 a.m. - notes revealed "Duoderm remains intact at this present time. No complaint of discomfort has been noted.” On August 15, 2008 at 10:49 PM - notes revealed “replaced Duoderm on buttocks drainage noted coming from area, will continue to observe until resolved." On August 16, 2008 at 5:34 a.m. - notes revealed "Duoderm remains intact at this time will continue to observe.” On August 16, 2008 at 10:04 a.m. - notes reveal "Duoderm remains intact at this time. To get out of chair on side. Will continue to monitor." On August 16, 2008 at 10:30 PM - notes revealed "Duoderm intact buttocks." 19 From: To: Eidetik 11/17/2008 16:15 #341 P.021/035 w. On August 17, 2008 at 3:57 a.m. - notes revealed "open to air at this time, no drainage observed, will continue to observe.” x. On August 17, 2008 at 10:55 a.m. - notes revealed "area remains open to air at this time with no drainage or bleeding being noted. Client denies any discomfort at this present time." y. On August 17, 2008 at 10:31 PM - notes revealed "area open to air. No bleeding or drainage noted. Will monitor." Z On August 18, 2008 at 2:55 a.m. - notes revealed "Bacitracin ointment applied to open areas noted this shift, signs and symptoms of pain and discomfort observed, will continue to observe until healed." aa. On August 18, 2008 at 9:14 a.m. - notes revealed “two small open areas continue to inner buttocks, approximately 1-2 cm in diameter each. No bleeding noted, left open to air. Bacitracin ointment applied, will continue to monitor." bb. On August 18, 2008 at 10:50 PM - notes revealed “areas on buttocks dry, no bleeding noted. Bacitracin ointment applied. Will monitor." ce, On August 18, 2008 at 5:53 a.m. - notes revealed at 3:30 a.m. “Bacitracin ointment applied to right buttock area." dd. On August 19, 2008 at 10:56 a.m. - notes revealed "no bleeding or drainage noted at this time. Will continue to monitor." ce. On August 20, 2008 at 6:16 a.m. ~ notes revealed "no drainage noted from open area to buttocks, no signs/symptoms discomfort when on bed rest, will continue to monitor." 20 From: 8g. ii. ji. To: Eidetik 11/17/2008 16:15 #341 P.022/035 On August 20, 2008 at 10:56 a.m. - notes revealed "no bleeding or drainage noted from buttock area. Client denies any discomfort at this present time. Will continue to monitor until resolved.” On August 20, 2008 at 10:45 PM ~ hotes revealed "client on bed rest from 7:00 PM, positioned to avoid pressure to open areas on buttocks. Had bowel movement, Slight bleeding from area noted when client's buttocks washed, states area sensitive to touch, treatment as ordered. Will continue to monitor." On August 21, 2008 at 4:31 a.m. - notes revealed "small amount of drainage noted coming from buttocks area at this time, applied medication treatment as ordered, will continue to observe.” On August 21, 2008 at 11:15 a.m. — notes revealed “no drainage noted at this time, Client denies any complaint at this present time." On August 22, 2008 at 3:51 a.m. - notes revealed "medicated cream applied to buttocks as ordered by physician, small amount of drainage noted at this time from buttock, will continue to observe." . On August 22,2008 at 11:01 am. - notes revealed "client denies any discomfort from buttocks at this time. No drainage noted at present time. Will continue to monitor until resolved." On August 22, 2008 at 10:49 PM - notes revealed “small open area remains buttock. No bleeding or drainage noted. Bacitracin ointment applied.” On August 23, 2008 at 4:43 a.m. - "applied treatment medication to area as ordered by physician, some drainage noted coming from area, will continue to observe." 21 From: oo. Pp. qq. ss. uu. To: Eidetik 11/17/2008 16:15 #341 P.023/035 On August 23, 2008 at 10:23 PM - notes revealed "area on buttocks remains. No bleeding or drainage noted this shift. Bacitracin ointment applied. Will monitor." On August 24, 2008 at 4:26 a.m. - notes revealed "no drainage noted this shift from buttocks, tured on to side at this time, will continue to observe." On August 24, 2008 at 4:34 a.m. - notes revealed "no drainage noted this shift from buttocks, tured on to side at this time, will continue to observe." On August 24, 2008 at 12:42 PM - notes revealed "no drainage noted at this time. Client up in chair for daily routine.” On August 24, 2008 at 9:46 PM - notes revealed "area to buttocks resolving. No bleeding or drainage noted. Will monitor." On August 25, 2008 at 9:51 ‘am. - notes revealed "ointment applied to inner buttocks area, no bleeding/drainage noted. Continue to be pinkish in color, slowly resolving. Will continue to monitor." On August 26, 2008 at 6:11 a.m. - notes revealed "small amount of blood noted on buttocks pm (as needed) ointment applied." On August 26, 2008 at 10:33 a.m. - notes revealed "no discomfort noted this far this shift. No bleeding noted at this particular time. Will continue to monitor." On August 27, 2008 at 6:00 a.m. - notes revealed no bleeding noted this shift bacitricin applied to area. . On August 27, 2008 at 1:32 p.m. - notes revealed no bleeding noted or any complaint of discomfort noted at this present time. 22 From: To: Eidetik 11/17/2008 16:15 #341 P.024/035 XX. On August 27, 2008 at 10:22 p.m. - notes revealed no bleeding noted from area buttocks, healing. yy. On August 28, 2008 at 4:54 am. - notes revealed "some drainage noted this shift. Medicated cream applied to all areas open on buttocks, will continue to observe." , 2Z. On August 28, 2008 at 10:38 PM - notes revealed “no drainage noted, area remains unchanged. Will observe." aaa. On August 29, 2008 at 3:48 a.m. - notes revealed "some drainage noted, applied medicated cream to two areas on buttocks, will continue to observe." bbb. On August 29, 2008 at 10:41 a.m. - notes revealed "no drainage or bleeding noted at this particular time. Client denies any complaints at this particular time. Will continue to monitor until completely resolved". ccc. On August 29, 2008 at 10:17 p.m. - notes revealed "no bleeding or drainage from area buttock. Will monitor." ddd. On August 30, 3008 at 4:05 a.m. - notes revealed "bleeding noted coming from areas on buttocks, applied medicated cream as ordered by physicians, will continue to observe." eee. On August 30, 3008 at 11:18 a.m. - notes revealed "no indication of pain at this time. Will continue to observe." fff. On August 30, 3008 at 9:42 p.m. - notes revealed "no complaints noted Bacitricin applied to area." 23 From: To: Eidetik 11/17/2008 16:15 #341 P.025/035 gge. On August 31, 2008 at 3:09 a.m. - notes revealed "Triamcinolone cream applied to open area on buttocks as ordered by physician, small aiount of drainage noted coming from areas on buttocks, will continue to observe.” hhh. On August 31, 2008 at 9:30 a.m. - notes revealed “client up in chair for morning routine. No complaints of discomfort at this time.” iii. On August 31, 2008 at 10:10 p.m. - notes revealed "client up for meal and no problems noted. No discomfort noted." 41. _ Petitioner’s representative reviewed Respondent’s Nurses Notes Section of the medical record of client number five (5) and noted the following from the nurse log report during the month of September: a On September 1, 2008 at 5:27 a.m. - notes revealed "Tyiamcinolone cream applied to draining area on buttocks, Tylenol 650 mg by mouth given for general discomfort, will continue to monitor." b. On September 1, 2008 at 9:59 a.m. - notes revealed "treatment rendered as ordered per physician. No bleeding noted at this time nor any verbal complaints noted at this time.” c. On September 1, 2008 at 11:00 p.m. - notes revealed "small amount bleeding noted from open area buttocks, cleansed with soap and water, Bacitracin ointment applied." d. On September 2, 2008 at 5:37 a.m. - notes revealed "client complained of pain to buttock and prn (as needed) Tylenol given." 24 From: To: Eidetik 11/17/2008 16:16 #341 P.026/035 On September 2, 2008 at 11:07 a.m. - notes revealed "treatment to open area on buttocks, no drainage noted; alert and smiling when up in wheelchair, no sign/symptoms discomfort in am." On September 2, 2008 at 10:13 p.m. - notes revealed "no bleeding from area buttocks noted. Area healing. Protective barrier applied. Will monitor." On September 3, 2008 at 5:38 a.m. - notes revealed "no bleeding noted to buttocks. Will continue to monitor.” On September 3, 2008 at 2:46 p.m. ~ notes revealed "Bacitracin ointment applied to open area buttocks after bath given at 9:30 a.m., no drainage or bleeding, no sign/symptoms discomfort." On September 3, 3008 at 10:46 a.m. - notes revealed "areas to buttocks resolving. Cleansed with soap and water, bacitracin ointment applied. Positioned on side to relieve pressure." On September 4, 2008 at 5:35 a.m. - notes revealed "area cleaned with soap and water and Bacitracin applied." On September 4, 2008 at 9:35 a.m. - notes revealed "no bleeding or drainage noted at this time. Client denies any pain at this time.” On September 4, 2008 at 10:39 p.m. - notes revealed "Bacitracin ointment applied to open area buttocks at 10:00 PM, no bleeding or drainage noted, no signs/symptoms discomfort." On September 5, 2008 at 6:05 a.m. - notes revealed "no bleeding noted to buttocks at this time. No complaints this shift.” 25 From: To: Eidetik 11/17/2008 16:16 #341 P.027/035 n On September 5, 2008 at 3:45 p.m. - notes revealed "no bleeding reported, will continue to monitor." 0. On September 5, 2008 at 10:22 p.m. - notes revealed "applied Triamcinolone ” cream to open areas on buttocks some bleeding noted will continue to observe. p. On September 6, 2008 at 6:02 a.m. - notes revealed "Bacitracin applied to buttocks no complaint voiced this shift.” q. On September 6, 2008 at 9:45 a.m. - notes revealed "client up this shift with no complaints being voiced. No bleeding or drainage has been noted." r On September 6, 2008 at 10:22 p.m. - notes revealed "small amount bleeding noted from area buttocks. Cleansed with soap and water, Bacitracin ointment applied." 8. On September 7, 2008 at 6:11 a.m. - notes revealed "large amount of drainage noted coming from buttocks, applied medicated cream to area, will continue to observe." L On September 7, 2008 at 2:49 p.m. - notes revealed “client up in wheelchair for meal. No bleeding noted since being back in chair. Will continue to monitor until completely resolved." . u On September 7, 2008 at 9:08 p.m. - notes revealed "no bleeding noted this shift. Bacitracin ointment applied to open area inner buttock. Will monitor." v. On September 8, 2008 at 5:48 a.m. - notes revealed "medicated cream applied to buttocks, small amount of light red drainage noted, will continue to observe.” 26 From: bb. cc, dd. ee. To: Eidetik 11/17/2008 16:16 #341 P.028/035 On September 8, 2008 at 10:53 a.m. - notes revealed “treatment to buttocks as ordered, no further bleeding or drainage observed; will continue to monitor.” On September 8, 2008 at 10:23 p.m. - notes revealed "small open areas on buttocks healing well. No bleeding or drainage noted. Triamcinolone ointment applied will continue to monitor." On September 9, 2008 at 6:24 a.m. - notes revealed "no bleeding noted to small open areas on buttocks. PRN triamcinolone ointment applied and no signs of discomfort noted." On September 9, 2008 at 9:49 a.m. - notes "revealed area remains open with no bleeding being noted. Client denies any discomfort at this present time. Will continue to monitor until resolved." On September 9, 2008 at 3:28 p.m. - notes revealed "client on bedpan noted to have some bleeding from open area. Duoderm applied to open area." On September 9, 2008 at 3:30 p.m. - notes revealed "open area noted to be linch by 1/2 inch. Will continue to monitor until resolved." On September 9, 2008 at 6:40 p.m. - notes revealed "Duoderm as needed. Start date: 9/09/08 apply Duoderm as needed to buttock area." On September 9, 2008 at 8:22 p.m. - notes revealed "Duoderxn intact to area buttock. No bleeding or drainage noted. To be 30 minutes after evening meal at _ 6:30 PM. Positioned on side to relieve pressure on buttocks.” On September 9, 2008 at 9:15 p.m. - notes revealed "repositioned to left side to relieve pressure. Duoderm remains intact to area right buttock. Triamcinolone cream applied to surrounding tissue. Will continue to monitor." 27 From: To:Eidetik 11/17/2008 16:16 #341 P.029/035 ff. On September 9, 2008 at 10:43 p.m. - notes revealed “resting quietly in bed." gg. On September 10, 2008 at 6:34 a.m. - notes revealed "Duoderm remains in place to client’s buttocks. No drainage noted at this time. Client slept well this shift. Client tumed. No complaints of pain voiced. Will continue to monitor." 42. That Petitioner’s representative reviewed the Physician Progress Notes section of Respondent’s medical record for client number five (5) and noted as follows: a. There were monthly entries in the record; b. There is no indication that the physician was aware of the current open areas on the client's buttocks; c. There are physician progress notes of July 26, 2007 that include, but are not limited to, "There is an area of a skin tear in (the client's) right gluteal fold area. Area is small, but there is some concern about friction causing this when sitting. Will have nursing contact wheelchair about seating in his chair. Otherwise we will use Duoderm on this. No other problems noted.” | d. Another progress note dated August 9, 2007 included, but was not limited to, "Also has an open area which is on [the] buttock. It is not a ducubitus it is just an open area. There is no evidence of any infection. Will use Duoderm and continue to monitor." 43. That Petitioner’s representative interviewed the physician of client number five (5) on September 11, 2008 who indicated as follows: a. That he believed he was notified of the wound on the client's buttock last Thursday, September 4, 2008; 28 From: a To:Eidetik 11/17/2008 16:16 #341 P.030/035 That he observed the wound on September 11, 2008, the day of the interview, and did not know why the client had a wound; That Duoderm may not be the best choice for the treatment of the client's wounds; That he will change the treatment. 44. That Respondent, as an intermediate care facility for the developmentally disabled, is required to provide nursing services in accordance with client needs, and to provide sufficient staff, qualified by training or experience, to properly care for the type and number of clients accepted by the facility. See, §§400.960(8) and 400.962(4), Fla. Stat. (2008), and 42 CER. 483.460(c). 45. Respondent intentionally or negligently failed to provide adequate nursing services or staff, qualified by training or experience, to properly care for client number five (5), including, but not limited to, Respondent’s failure to: a. b. Assess the client after the development of open areas requiring medical care, Administer medications and treatments without prescription or authorization by a duly licensed practitioner authorized by law to prescribe medications or treatments; Notify the physician of developed and persistent wounds which failed to improve despite treatment, be said treatment prescribed or self initiated; Evaluate and monitor care provided and its effectiveness in addressing ongoing open wounds on client number five (5); Provide care under the supervision of an appropriate professional; Ensure that licensed practical nurses are appropriately supervised to assure care quality; 29 From: To: Eidetik 11/17/2008 16:16 #341 P.031/035 46. That the Agency determined that the above constitutes grounds for the imposition of a Class I deficiency in that it presents an imminent danger to the residents or guests of the facility or a substantial probability that death or serious physical or emotional harm would result therefore. 47. That the Agency cited the Respondent for a Class I violation in accordance with Section 400.967(3)(a), Florida Statutes (2008). WHEREFORE, the Agency intends to impose an administrative fine in the amount of $5,000.00 against Respondent, an intermediate care facility in the State of Florida, pursuant to §§ 400.967(3)(a) and 400.969(1 ), Florida Statutes (2008). COUNT TIT 48. The Agency re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 49. That the Petitioner re-alleges and incorporates the provisions of Counts I and II of this complaint as if fully recited herein. 50. That pursuant to Florida law, in addition to the grounds provided in authorizing statutes, gtounds that may be used by the agency for denying and revoking a license or change of ownership application include any of the following actions by a controlling interest. ..(b) An intentional or negligent act materially affecting the health or safety of a client of the provider; (c) A violation of this part, authorizing statutes, or applicable rules. §408.815(1), Florida Siatutes (2008) $1. That the Respondent has been cited with two separate violations of law regulating intermediate care facilities for the developmentally disabled 52. That Respondent has committed intentional or negligent act materially affecting the health or safety of clients of the provider. 30 From: To: Eidetik 11/17/2008 16:17 #341 P.032/035 53. That based thereon, the Agency seeks the revocation of the Respondent’s licensure. WHEREFORE, the Agency intends to revoke the license of the Respondent to operate an intermediate care facility in the State of Florida, pursuant to § 408.815(1), Florida Statutes (2008). > Respectfully submitted this 15 day of November, 2008. iY, LL 0 Fld. Bar. No. 566365 Counsel for Petitioner Agency for Health Care Administration 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 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 attomey 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 Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3,MS #3, Tallahassee, FL 32308;Telephone (850) 922-5873. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST 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. CERTIFICATE OF SERVICE THEREBY CERTIFY that a tme and correct copy of the foregoing has been served by USS. Certified Mail, Return Receipt No. 7008 0500 0001 0420 4027 to: Facility Administrator Sharon Brown Jamison, Amelia Island Care Center, 2700 Atlantic Avenue, Fernandina Beach, Florida 32034, by U.S. Certified Mail, Return Receipt No. 7008 0500 0001 0420 4034 to: Registered Agent Frank E. Maloney, 5 West MacClenny Avenue, MacClenny, Florida 32063 on November }3_, 2008: Thomas 5 Seftidr Aftomey 31 From: To. Eidetik 11/17/2008 16:17 #341 P.033/035 Copies furnished to: Sharon Brown Jamison, Administrator Amelia Island Care Center 2700 Atlantic Avenue Fernandina Beach, Florida 32034 (U.S. Certified Mail) Frank E. Maloney Registered Agent : 5 West MacClenny Avenue MacClenny, Florida 32063 (US. Certified Mail) Nancy Marsh, Field Office Manager Agency for Health Care Administration Building A, Suite 115 921 North Davis Street Jacksonville, Florida 32209 Thomas J. Walsh II, Esq. Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, Florida 33701 (Interoffice) 32 SENDER: COMPLET _m Complete items 1, 2, .«d 3. Also complete : 1 item 4 if Restricted Delivery is desired. —— x Cf < ge VN ? Addressee ‘'m Print your name and address on the reverse - : B. Received by ( Printed Name) so that we can return the card to you... ‘Ml Attach this card to the back of the mailplece, or on the front if space permits. : 1. Article Addressed to: Sharon Brown Jamison Administrator Amelia Island Care Center 3. Service Type 2700 Atlantic Avenue Sek Certified Mait 1 Express Mall Oi Registered e-Retur Receipt for Merchandise Ol insured Mail 1 G.0.D. : Fernandina Beach, Florida 32034 onl 7008 0500 0001 0420 402? Domestic Return Receipt 102595-02-M-1540 PS Form 3811, February 2004 SENDER: COMPLETEg ® Complete items 1, 2, uid 3. Also complete item 4 if Restricted Delivery is desired. @ Print your name and address on the reverse $0 that we can return the card to you. @ Attach this.card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: B. Received by (Printed Name) a er Cronk & a Senne 68 D. Is delivery address different fromjtem 1? 1 Yes tf YES, enter delivery address below: [1 No Frank E. Maloney Registered Agent 5 West MacClenny Avenue MacClenny, Florida 32063 3. Service Type “$LCertiied Mall 1 Express Mail Cl Registered . 4@CReturn Receipt for Merchandise 1 Insured Mail == (1 C.0.0. 4, Restricted Delivery? (Extra Fee) -OyYes RO0SOl] b 34 malta £5 7008 O500 0002 o4#0 4034 PS Form 3811, February 2004 Domestic Return Receipt 4

Docket for Case No: 08-006227