STATE OF FLORIDA AGENCY FOR HEALTH CARE HOTT OF OS £0 ~3 Pa 3 STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, VS. Case Nos. 2008013143 2008013144 BRANDON HEALTH CARE ASSOCIATES, LLC, d/b/a BRANDON HEALTH 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 BRANDON HEALTH CARE ASSOCIATES, LLC, d/b/a BRANDON HEALTH AND REHABILITATION CENTER, (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2008), and alleges: NATURE OF THE ACTION This is an action to change Respondent’s licensure status from Standard to Conditional commencing November 7, 2008 and ending December 19, 2008, and impose an administrative fine in the amount of two thousand five hundred dollars ($2,500.00), based upon Respondent being cited for one Isolated State Class II deficiency. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60 and 400.062, Florida Statutes (2008). 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), Chapters 400, Part II, and 408, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 4. Respondent operates a 120-bed nursing home, located at 1465 Oakfield Drive, Brandon, FL 33511, and is licensed as a skilled nursing facility license number 130470969. 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. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. That pursuant to Florida law, all licensees of nursing homes facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the agency. § 400.022(1)(1), Fla. Stat. (2008). 8. 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). 9. That on or about November 7, 2008, the Agency completed a complaint survey (CCR# 2008011414), of Respondent’s facility. 10. That based upon observation, the review of records, interviews, Respondent failed to ensure the provision of protective and support services and to prevent injuries to a resident resulting in a transfer of the resident to a more acute health facility for examination and x-rays, with resultant bruising, the same being contrary to law. 11. That Petitioner’s representative reviewed Respondent’s records regarding resident number three (3) during the survey and noted as follows: a. The resident was admitted to the facility on April 18, 2007, per the admission data sheet; b. The resident had multiple diagnoses including Dementia, and Osteoarthritis; c. The resident's Minimum Data Set (MDS) revealed a significant change MDS dated January 7, 2008 which was coded as the resident having had a fall in the past 31 to 180 days; d. A second significant change MDS, dated March 11, 2008, was coded as the resident having had a fall in the past 30 days, in the past 31 to 180 days and a fracture in the last 180 days; . A third quarterly MDS, dated September 2, 2008, was coded as the resident having had a fall in the past 31 to 180 days; The Resident Fall Assessment Protocol, dated March 11, 2008, noted the resident was eased to the floor during transfer and was found to have fractured the proximal fibula. "[The resident] is at risk for further fall related injury complications, which include currently being non-weight bearing....currently dependent on staff for transfers.” Resident progress notes reflected the following: On November 5, 2008 at 1630 (4:30 p.m.) "At 1600 (4:00 p.m.) this nurse was called to resident's room by a care specialist. Upon entering the room found one care specialist kneeling on floor next to the resident and another care specialist attempting to release left leg from Hoyer pad. Resident was in prone position on floor with left side of head up against the foot of the Hoyer at the base of the lift. Resident was being transferred from bed to wheelchair per care specialist. The resident leaned to the side and flipped out of the sling. The care specialist attempted to catch the resident but was unable. Resident alert pointed to head when asked if [the resident] had any pain - able to move legs - with my assistance and two care specialists, resident turned onto [] back - able to move all extremities without pain. Hematoma noted to left side of head. Resident alert and oriented. Ice applied to forehead. Vital Signs 160/78, pulse 100, respiration 22, temperature 97.4 degrees Fahrenheit. 12. That Petitioner’s representative interviewed a private duty aide for resident number three (3) during the survey who indicated as follows: a. On November 5, 2008 she had to leave early and was not there during above incident; She stays with the resident at least five (5) days a week from about 9:30 to 4:30 p.m. or later, if needed; | The facility nursing assistants give the care to the resident; The private duty aide indicated that the bump has gone down in size and is much better today. 13. That Petitioner’s representative observed resident number three (3) on November 7, 2008 at 2:45 p.m. and noted as follows: a. b. Cc. d. The resident had a bump on the left side of the forehead; There is bruising on the posterior neck worse on the left side and left lateral side spreading to the left shoulder both posteriorly and anteriorly; There is bruising on the chest on the left breast area; The resident complained of left shoulder and back pain at this time. 14. That Petitioner’s representative interviewed a family member of resident number three (3) on November 7, 2008 who indicated as follows: a. The family member was concerned with the resident's safety since the resident had had multiple falls in the facility, at least four the family member could remember in approximately the past nine (9) months; The resident has told the family member that the resident is afraid now of falling whenever being transferred by staff. 15. That Petitioner’s representative interviewed Respondent’s certified nursing assistant who had transferred resident number three (3) with the Hoyer lift on November 5, 2008 who indicated as follows: d. At 4:00 p.m. she had put the lift sling under the-resident "the correct way" while the resident was still in bed, criss-crossing the leg straps, and had lifted the resident and pulled the resident away from the bed; While she had the resident up in the air, the resident leaned to the left side and started to fall sideways; She got to her knees and tried to hold the resident by the trunk, but could not get to the resident's head; The resident was a one assist with Hoyer lift transfers. 16. That Petitioner’s representative further reviewed Respondent’s records regarding resident number three (3) during the survey and noted as follows: a. Progress notes on January 24, 2008 at 1400 (2:00 p.m.) reflected "patient had to be lowered on the floor after using the toilet, knees buckled up, feeling weak. No apparent injury.” Progress notes on February 7, 2008 at 2015 (8:15 p.m.) recorded, "Staff lowered patient to the floor during transfer from bed to chair. No apparent injury noted. Range of motion within normal limits"......at 2045 (8:45 p.m.) "Patient in bed complaining of pain on left shoulder and left side of back." Progress notes on February 17, 2008 at 0810 (8:10 a.m.) noted "During transfer from bed to wheelchair, resident knees gave and resident went down onto [] knees. Resident placed onto back. Range of motion done, complaining of knee pain - able to bend and extend knees though no facial grimacing noted. Placed into wheelchair then into bed with 3 assists." Progress notes of February 17, 2008 at 1730 (5:30 p.m.) read "X-rays result obtained, left minimally displaced acute fracture of the proximal fibula." Progress notes of February 18, 2008 at 3:15 a.m. reflect that the resident was sent to the hospital via ambulance, and came back with a soft splint on the left leg; February 20, 2008 progress notes of 9:30 a.m., reflect, "pt up to w/c with hoyer lift-and standby of 2 BCS. Tol well." The "Care Plan Attendance Log," dated April 1, 2008, included a note on the back of the form which stated, "Spoke with daughter r/t decreased ability to ambulate & p.o.c. changes. Will try more therapy." The April 2, 2008 therapy note reflected, “patient uncooperative today during tx session, unwilling to stand." | During the April 3, 2008 physical therapy session, it is noted that the resident "attempted several sit--stands (x8), but, unable to take any steps with fear of falling.” Progress notes on April 8, 2008 at 4:15 p.m. noted "At 2:15 p.m. patient tried to stand self in B/R by grabbing bar. CNA caught patient and tried to sit [the resident] down. Patient started to fall so CNA lowered [the resident] to the floor gently. No injuries." The note also described the resident as needing "total care with bed mobility, ADLs, & transfer to w/c." April 10, 2008 therapy notes reflected that the therapy staff "trained NSG staff with transfers sit--stand with mod A of 2 pulling up on hand rail x 20 sec., 10 " sec. The resident was discharged from therapy on April 11, 2008 noting "Pt. uncooperative with signs of delusion as pt. thinks P.T. is going to kill [the resident] & P.T. is after [the resident’s] baby. Restorative training-for transfers sit--stand with grab bar.” Progress notes of April 17, 2008 at 9:00 a.m. reflected the use of two staff, but use of two staff was not reflected in the current care plan for use of the hoyer lift. The progress stated, "Up in hoyer lift & 2 people to w/c. LOA to ortho follow-up." The care plan for the resident reflected in problems identified as "At risk for fall related injury related to a history of falls" onset date September 2, 2008, and required "2 person transfers or mechanical lift for transfer.” The September 11, 2008 care plan meeting note reflected that the resident would be picked up again for "decline in ambulation skills, weakness, and knee buckling." Progress notes of September 15, 2008 at 1620 (4:20 p.m.) noted "Attempting to transfer resident to toilet with 2 person. Resident counted with staff, stood, but unable to maintain standing position, knees buckling. Sat on edge of toilet, sliding toward edge, attempted to assist to stand and reposition, unable to bear weight. Lowered to floor with 2 assist, required 3 assist back to chair, no injury noted." That the nursing assistants' resident care information revealed that prior to the November 5, 2008 incident, the resident was to have two (2) person transfer with gait belt to toilet, and Hoyer lift in and out of bed; q. After the incident on November 5, 2008, it was amended to have two (2) person Hoyer lift in and out of bed. r The November 6, 2008 updated care plan included the revised intervention of “may use 2 person and mech lift for transfers.” s. Physical therapy evaluated the resident on November 6, 2008, after the hoyer slip, and concluded, "recommend 2 people with mechanical/hoyer lift transfer. Patient was recently discharged from P.T. services--currently at max rehabilitation potential difficulty in mobility secondary to morbid obesity, B knee O.A. and poor motivation.” 17. That Respondent did not mandate additional interventions designed to provide additional protections from the resident’s risk of fall and potential injury therefrom when it revised the resident’s care plan in November 2008. 18. That Respondent’s response to the November 5, 2008 fall by the amendment of the resident’s care plan provided only optional staff assistance when transfers, including mechanical transfer, of the resident were effectuated despite the recommendation of physical therapy that two person assist be mandated with mechanical lift. 19. That these failures, collectively and individually, reflect Respondent’s failure to ensure that adequate and appropriate health care and protective and support services was provided to residents, including, but not limited to the failure to provide interventions for resident three (3) and the risk of falls where: a. The failure to revise interventions relating to the risk of falls prior to November 2008 where the resident’s history reflects the use of multiple person assistance in achieving transfer of the resident; b. The failure to revise interventions relating to the risk of falls prior to November 2008 where the resident’s physical therapy proved ineffective; c. The use of two (2) persons to assist in Hoyer transfer was intermittent; d. The failure to implement further fall preventions in the September 2008 care plan despite continued events related to transfer and the ineffectiveness of and discharge from physical therapy; e. Despite the February fracture suffered by the resident, the ongoing history of falls reflecting the insufficiency of interventions, and the fall of November 5, 2008, the failure to implement mandatory additional staff assistance or other safeguards when Hoyer transfer is indicated. 20. That Petitioner’s representative reviewed Respondent’s records regarding resident number two (2) during the survey and noted as follows: a. The resident was admitted to the facility on August 13, 2008 per admission data sheet. The resident had been admitted to the facility for rehabilitation following hospitalization for a right hip fracture and status post hip surgery; b. The resident's Minimum Data Set (MDS) revealed an admission MDS dated August 21, 2008 which noted that the resident had fallen within the past 30 days and had had a hip fracture in the last 180 days; c. The Resident Fall Assessment Protocol dated August 21, 1008 noted the resident had a fall at home with hip fracture and at risk for additional fall related injury. Complications included Dementia, hypertension, anemia and use of psychoactive medications. The resident has a clip alarm and a pressure sensitive alarm which is used at all times to immediately notify staff, if the resident attempts to get up per self. Therapy for gait training - will care plan to prevent additional fall related injury; . A care plan dated August 21, 2008 addressing risk for fall related injury related to fall at home with hip fracture and had several approaches listed, including one dated September 18, 2008 for a clip alarm while in wheelchair, and pressure sensor pad in bed; On September 23, 2008 there were two additional approaches noting room closer to nursing station, and a scoop mattress; On October 9, 2008 there was an added approach for an alarm belt in the wheelchair; The resident’s September 2008 physician orders revealed the following orders, dated August 14, 2008: 1. May have clip alarm at all times (bed/chair) due to decreased safety awareness. 2. Bed/chair sensor pad at all times due to poor safety awareness. Check functioning of alarms daily. 3. Velcro alarm belt; These orders were discontinued on September 18, 2008, and new orders were received on that same date for a clip alarm on while in the wheelchair, and a pressure sensor pad while in bed; The resident's Multi-shift care track dated September 23, 2008 at 0145 (1:45 a.m.) noted the following: "Called to resident's room by BCS (Brandon Care Specialist, which is the facility's title for certified nursing assistants) resident sitting on floor beside bed. No injury apparently, no decrease in range of I 21, motion and no first aid needed." At 12:00 noon the nursing narrative note noted "that the right leg from hip to knee is very swollen, patient denies pain." The physician was contacted and x-rays were ordered. A September 23, 2008 right knee x-ray report revealed no bone abnormalities and the right hip x-ray report noted "a fracture is noted roughly 60% along the length of the intramedullary portion of the prosthesis. This does not appear to be acute as there is some callus forming. No dislocation is seen." A note dated October 3, 2008 from the orthopedic surgeon, who had performed the surgery on the resident's right hip fracture, read: "Patient seen for follow up on 08/22 where x-ray showed good positioning of hemiarthroplasty." At today's visit, "x-ray demonstrates femoral shaft fracture. It appears there is already significant callus formation present which would represent the fracture is not new. As per family member, patient sustained a fall in the nursing home on 09/23/08." The physician ordered no weight bearing for the resident; The October 8, 2008 multi-shift care track narrative noted at 1930 (7:30 p.m.) staff heard alarm going off in the hallway and staff found patient sitting on the wheelchair's foot rest. No apparent injury noted. Denies any pain or discomfort. Physician and family member notified. That these failures, collectively and individually, reflect Respondent’s failure to ensure that adequate and appropriate health care and protective and support services was provided to residents, including, but not limited to the failure to provide interventions for resident two (2) and the risk of falls where no action was taken to address, evaluate, or implement alternative fall prevention interventions for the resident after said interventions proved ineffective to prevent a fall of September 23, 2008. 22. That the Agency determined Respondent had not provided the necessary care and services and had failed to assure each resident adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan and cited this deficient practice as an Isolated State Class II deficiency. 23. The Agency provided Respondent with the mandatory correction date for this deficient practice of November 7, 2008. WHEREFORE, the Agency seeks to impose an administrative fine in the amount of $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(8)(b), Florida Statutes (2008). COUNT II 24. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I of this Complaint as if fully set forth herein. 25. Based upon Respondent’s one cited State Class II deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part II of Florida Statute 400, or the rules adopted by the Agency, a violation subjecting it to assignment of a conditional licensure status under § 400.23(7)(a), Florida Statutes (2008). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a skilled nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2008) commencing November 7, 2008 and ending December 19, 2008. Respectfully submitted this 6 day of January, 2009. ’ Thomas J. Walsh II, Esquire Fla: Bar. No. 566365 Agency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1525 (office) DISPLAY OF LICENSE Pursuant to § 400.23(7)(e), Fla. Stat. (2005), 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 US. Certified Mail, Return Receipt No: 7008 0500 0001 0420 4249 on January _§ _, 2009 to: Kenneth Perry, Administrator, Brandon Health & Rehab Center, 1465 Oakfield Drive, Brandon, FL 33511, and by U:S. Mail to Corporation Service Company, Registered Agent, 1201 Hays Street, Tallahassee, Florida 32301. “y? foe Thomas‘J _ Walsh, II, Esquire SE 4 Copies furnished to: Kenneth Perry, Administrator Brandon Health & Rehab Center 1465 Oakfield Drive Brandon, FL 33511 (U.S. Certified Mail) Patricia Caufman Field Office Manager 525 Mirror Lake Dr., 4 Floor St. Petersburg, Florida 33701 (Interoffice) (nteroffice) Corporation Service Company Registered Agent 1201 Hays Street Tallahassee, FL 32301-2525 (U.S. Mail) Thomas J. Walsh, II, Esquire Senior Attorney Agency for Health Care Admin. 525 Mirror Lake Dr, 330G St. Petersburg, Florida 33701 15

Docket for Case No: 09-000580