"'

STATE OF FLORIDA

AGENCY FOR-HEALTH CARE ADMINISTRATI NOV -5 P 2: ti3

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

Petitioner,

v.

WOOD LAKE HEALTH CARE ASSOCIATES, LLC d/b/a WOOD LAKE NURSING AND REHABILITATION CENTER,

Respondent.

AHCA No.: 2009003690

AHCA No.: 2009003691

DOAH No.: 09-3737

RENDITION NO.: AHCA-09- I 2 13 -5-0LC

FINAL ORDER

Having reviewed the administrative complaint dated June 26, 2009, attached hereto and incorporated herein (Exhibit 1), and all other matters of record, the Agency for Health Care Administration ("Agency") has entered into a Settlement Agreement (Exhibit 2) with the other party to these proceedings, and being otherwise well-advised in the premises, finds and concludes as follows:

ORDERED:

1. The attached Settlement Agreement is approved and adopted as part of this Final Order, and the parties are directed to comply with the terms of the Settlement Agreement.

   
   

   Filed November 9, 2009 12:00 PM Division of Administrative Hearings.

   
   

2. Upon full execution of this Agreement, Respondent agrees to pay

   
   

   $1,875.00 in administrative fines to the Agency within thirty (30) days of the entry of the Final Order. Respondent accepts the assignment of conditional licensure status commencing March 5, 2009 and ending April 14, 2009.

3. A check should be made payable to the "Agency for Health Care Administration." The check, along with a reference to these case numbers, should be sent directly to:

   Agency for Health Care Administration Office of Finance and Accounting Revenue Management Unit

   2727 Mahan Drive, MS #14

   Tallahassee, Florida 32308

   
   

4. Unpaid amounts pursuant to this Order will be subject to statutory interest and may be collected by all methods legally available.

5. A conditional license is imposed commencing March 5, 2009 and ending April 14, 2009.

6. Each party shall bear its own costs and attorney's fees.

   
   

7. The above-styled cases are hereby closed.

DONE and ORDERED this 4-ctay , 2009,

in Tallahassee, Leon County, Florida.

:a.:,ecretary

ealth Care Administration

A PARTY WHO IS ADVERSELY AFFECTED BY THIS FINAL ORDER IS ENTITLED TO JUDICIAL REVIEW WHICH SHALL BE INSTITUTED BY FILING ONE COPY OF A NOTICE OF APPEAL WITH THE AGENCY CLERK OF AHCA, AND A

.,

SECOND COPY, ALONG WITH FILING FEE AS PRESCRIBED BY LAW, WITH THE DISTRICT COURT OF APPEAL IN THE APPELLATE DISTRICT WHERE THE AGENCY MAINTAINS ITS HEADQUARTERS OR WHERE A PARTY RESIDES. REVIEW OF PROCEEDINGS SHALL BE CONDUCTED IN ACCORDANCE WITH THE FLORIDA APPELLATE RULES. THE NOTICE OF APPEAL MUST BE FILED WITHIN 30 DAYS OF RENDITION OF THE ORDER TO BE REVIEWED.

Copies furnished to:

..

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of this Final Order was

served on the above-named person(s) and entities by U.S. Mail, or the method designated, on this the , day of /)yue,,,,--- , 2009.

Richard J. Shoop Agency Clerk

Agency for Health Care Administration 2727 Mahan Drive, Building #3

Tallahassee, Florida 32308

(850) 922-5873

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

Petitioner,

v.

WOOD LAKE HEALTH CARE ASSOCIATES, LLC d/b/a WOOD LAKE NURSING AND REHABILITATION CENTER,

AHCA No.: 2009003690

AHCA No.: 2009003691

Return Receipt Requested: 7008 0500 0002 0764 8384

7008 0500 0002 0764 8780

Respondent.

I

ADMINISTRATIVE COMPLAINT

COMES NOW the State of Florida, Agency for Health Care Administration (hereinafter "ARCA"), by and through the undersigned counsel, and files this administrative complaint against Wood Lake Health Care Associates, LLC d/b/a Wood Lake Nursing and Rehabilitation Center (hereinafter "Wood Lake Nursing and Rehabilitation Center") pursuant to Chapter 400, Part II and Section 120-60, Florida Statutes, (2008) hereinafter alleges:

NATURE OF THE ACTION

1. This is an action to impose an administrative fine in the amount of $2,500.00 pursuant to Sections 400.23(8)(b), Florida Statutes (2008),[AHCA No.: 2009003690].

   
   

   EXHIBIT

   I

   
   

2. This is an action to impose a conditional licensure rating pursuant to Section 400.23(7)(b), Florida Statutes (2008),[AHCA No. 2009003691].

   
   

   JURISDICTION AND VENUE

   
   

3. This court has jurisdiction pursuant to Section

   
   

   120.569 and 120.57, Florida Statutes (2008), and Chapter 28-106, Florida Administrative Code.

4. Venue lies pursuant to Section 120.57, Florida Statutes (2008), and Rule 28-106.207, Florida Administrative Code (2008).

   PARTIES

   
   

5. AHCA is the regulatory authority with regard to skilled nursing facilities licensure pursuant to Chapter 400, Part II, Florida Statutes (200 ), and Rule 59A-4, Florida Administrative Code.

6. Wood Lake Nursing and Rehabilitation Center operates a 120-bed nursing home located at 6414 13t h Road South, West Palm Beach, Florida 33415. Wood Lake Nursing and Rehabilitation Center is licensed as a skilled nursing facility under license number 13390962. Wood Lake Nursing and Rehabilitation Center 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

   
   

   WOOD LAKE NURSING AND REHABILITATION CENTER FAILED TO ENSURE THAT RESIDENTS RECEIVED TIMELY ASSESSMENT AND TREATMENT DURING A MEDICAL EMERGENCY.

   
   

   SECTION 400.022(1)(1), FLORIDA STATUTES

   
   

   (RIGHT TO ADEQUATE AND APPROPRIATE HEALTH CARE STANDARD) CLASS II

7. AHCA re-alleges and incorporates (1) through (6) as if fully set forth herein.

8. Wood Lake Nursing and Rehabilitation Center was cited with one (1) Class II deficiency as a result of a licensure surveys conducted on March 5, 2009.

9. Based on observations, record reviews and interviews, it was determined that the facility failed to ensure that 4 of

   27 sampled residents ·received timely assessment and treatment during a medical emergency, pain management services and lymphadema treatment (RlO, R9, R17, R2) The findings include the following.

10. Based on observations, record reviews and interviews, the facility failed to ensure that 4 of 27 sampled residents received timely assessment and treatment during a medical emergency, pain management services and lymphedema treatment (Residents #10, #9, #17, and #2). The findings include the following.

    
    

11. The Surveyor observed Resident #10 during the initial tour, accompanied by the Staff Nurse on 3/3/09 at approximately 8:55 AM. The resident was observed to be sleeping on an air mattress. The following timeline describes events that occurred from 11:30 AM to 12:18 PM.

    1. 11:30 AM: The Surveyor observed that the Resident was no longer in his/her room and approached the Nursing Desk to ask the Unit Manager (Assistant Director of Nursing) the location of the Resident and where the resident had lunch. The Manager pointed to the resident who was positioned directly in front of the Nursing Desk and stated, "He/She's right there. He/she has had a change in condition and I called the Social Worker. I'm going to have the nurse take him/her to the room and do an assessment."

    2. 11:31 AM: The Surveyor walked around the desk to face the resident and observed that the resident's eyes were closed, a small amount of saliva was draining out of the left side of his/her mouth and his/her respirations were rapid and shallow. The Surveyor spoke to the resident but received no response. An Activity staff member approached the resident and began to rub his/her arm and was unsuccessful in her attempts to obtain a response.

    3. 11:35 AM: The Surveyor checked the Resident's Clinical Record and noted that the record indicated that the

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       resident was to have a full Cardio Pulmonary Resuscitation. Upon returning to the Nursing Desk, the Surveyor noted that the Resident was no longer positioned directly in front of the Nursing Desk. The Surveyor began to walk to the resident's room to conduct further observations.

    4. 11:50 AM: When the Surveyor reached the door to the Resident's room, the Surveyor observed that the Resident was not in his/her bed as expected. The Surveyor looked back towards the Nursing Desk and observed Resident #10 positioned approximately 12 feet away from the desk, unattended in the hall. The Surveyor walked towards the resident and upon reaching the resident, a Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) approached the resident as well. The LPN directed a Physical Therapist to take the resident to his/her room.

    5. 11:55 AM: Upon reaching the room, the Physical Therapist attempted to obtain a response from the resident by rubbing his/her arms and speaking to him/her. The Physical Therapist (PT) held the resident's wrist and when asked if she could get a pulse stated, "I can't it's thready." The Licensed Practical Nurse (LPN) was present in the room at this time assisting the roommate into a wheelchair, positioned with her back to Resident #10, the PT and the Surveyor. The LPN exited the room with the roommate at that time. The PT stated that she

       
       

       was going to get assistance from the CNA' s to put the resident into the bed and left the resident unattentl.ed except for the Surveyor. Neither the LPN nor Physical Therapist utilized the call bell or telephone to summon emergency assistance.

    6. 11:56 AM: The Unit Manager entered the room and was also unsuccessful in her attempts to obtain a verbal response from the resident. The Resident's mouth was now open and slack. The Unit Manager asked where the LPN was, to which the Surveyor replied that she did not know. The Unit Manager went to the doorway and yelled in the hall for the Nurse to come immediately.

    7. 11: 58 AM: The LPN entered the room, approached the resident and began to apply a sternal rub. The resident remained unresponsive. Two CNA's entered the room pushing a Hoyer Lift machine. The LPN placed a pulse oximeter on the resident's right wrist and a reading of 94% and 29 were observed. The LPN stated that the 94% indicated the resident's oxygen saturation and the #29 indicated his/her pulse. The LPN

       had a stethoscope in her hand, but did not check the resident's respirations or make any attempts to obtain a pulse. The LPN stated, "He/she just got back from having the Pacemaker

       replaced. We were unable to get his/her pulse the last time too." The LPN and the two CNA' s transferred the resident from the wheelchair to the bed with a mechanical lift. During the

       
       

       
       

       transfer the resident verbalized the words, "help, help me" in a barely audible voice.

    8. 12:06 PM. The Surveyor again asked the LPN if she

       
       

       had taken the resident's blood pressure, pulse and respirations. The Nurse assessed the resident's blood pressure and stated it was 90/60. The Nurse did not attempt to assess the resident's pulse and/or respirations at that time. As the CNA's exited the room, the LPN told them "you'd better call 911". The LPN then exited the room again leaving the resident unattended with the Surveyor.

    9. 12:08 PM: The 911 Paramedic Personnel entered the resident's room at 12:08 and immediately began assessing the resident. The LPN returned to the room and was asked by the Paramedics what the resident's vital signs and blood sugar was. The LPN stated that the blood pressure was 90/60, pulse 29, oxygen saturation 94% and that she had not assessed the respirations or taken a blood sugar measurement. The Unit Manager was present at that time and informed the Paramedics that the resident had only consumed a bottle of Boost that morning. The LPN took a blood sugar reading and informed the Paramedics that it was 378. The Paramedics stated that the resident was in 1st Degree Heart Block, had a right bundle branch block and the Pacemaker was not firing. Her blood pressure was assessed by the Paramedics a 113/72. The Paramedics

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       asked when and if the resident	had last received Insulin.	The
       LPN exited the room to obtain	the requested information.	The

       
       

       Unit Manager was present in the room at this time and communicated with the Paramedic staff regarding the resident's medical history.

    10. 12:14 PM: The resident coughed twice. The LPN returned to the room and informed the Paramedics that the resident had received 4 units of Insulin at 6:30 AM.

    11. 12:18 PM: Paramedic Personnel transported the resident to the Hospital. Surveyor requested a copy of facility policy and procedure for assessing unresponsive residents from the Unit Manager.

12. An interview was conducted with the Director of Nursing (DON) and the Administrator: at 12:35 PM, immediately following the preceding events. The Surveyor informed the DON and Administrator of the events/observation of Resident #10 and asked the DON how facility staff should respond when a resident is unresponsive.

13. The DON stated that she was unaware of any facility policy/procedure or protocol at that time. She then stated that it is a standard of nursing practice to assess a resident immediately, have an emergency cart on the Unit and that staff are certified to perform CPR. Blood sugar levels should be done on all unresponsive patients and the family and physician

    8

    
    

    notified. The DON agreed that the emergency medical situation of Resident #10 required immediate assessment by facility staff She stated that a Crash Cart is positioned next to the Nurses Desk and available for use.

14. Facility staff do not administer drugs, however a defibrillator, suction machine and oxygen are on the cart and available for use when a resident is unresponsive. The Administrator stated that there was no facility Emergency Response Policy, but that it was a standard of practice to perform an immediate assessment of the resident and provide CPR and other measures. The DON confirmed that the assessment should include an immediate assessment of vital signs, blood sugar,

    application of oxygen, Resuscitation (CPR).

    and if necessary Cardio Pulmonary

15. At 1:10 PM, the Staff Development Nurse confirmed that

    
    

    there was no facility policy/procedure for the emergency management of residents. At 1:15 PM, the DON and Administrator returned and stated that there was no in house policy for emergency management of residents, but that they would request the information from the Corporate Office. They have a Corporate Policy that was recently updated and has gone to the facility's Quality Assurance Meeting for review, however, it has not been adopted yet.

    
    

    
    

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16. The Corporate Policy for Management of an Unresponsive Resident was provided to the Surveyors at 1:26 PM. Review of the policy reveals the following:

    1. Residents that are found to be unresponsive will be evaluated to determine if they are breathless and pulse less. Residents that are determined to be breathless and pulse less will be treated as indicated by their advance directives.

    2. The Nurse assigned to provide care will be aware of the code status of the residents in their assignment. Code status will be identified in the medical record.

    3. Management of an unresponsive resident without a "Dci Not Resuscitate Order". Obtain apical pulse and respiratory

       .rate. Call 911 if the patient is determined to be breathless and pulse less. Initiate CPR. Assist Emergency response team as indicated. Notify physician and document notification and any physician orders. Notify family and/or legal representative and document notification. Document unresponsive incident, notification of 911, CPR initiation and resident disposition.

    4. CPR is to be initiated and 911 notified for any resident that is found breathless and pulse less that does not have an order for "Do Not Resuscitate".

17. An interview was conducted at 2:00 PM with the LPN who failed to promptly assess Resident #10 that morning. The LPN was

    
    

    asked if the Resident had been responsive that morning. The LPN stated that he/she was speaking and responsive that morning.

18. Review of the personnel file for the LPN who cared for Resident #10 on 3/3/09 reveals that the she successfully completed the American Heart Association program for Healthcare Providers in CPR on 6/2/08. The file also reveals that LPN was disciplined for failure to properly assess and administer emergency treatment to an unresponsive resident on 8/21/08.

19. A meeting was held with the Administrator and Director of Nursing and the Survey Team at 3:40 PM. The Administrator stated, "Yes, we understand that the LPN failed to conduct a prompt assessment when the resident had a change in condition and did not follow the standard of care in treating an unresponsive resident."

20. Review of the facility's Quality Assurance data reveals that the Corporate Policy for Management of Unresponsive Residents was brought to the Committee on 12/9/08.

21. Review of the Clinical Record of Resident #10 revealed a Care Plan for Pacemaker with interventions that included the following: Monitor vital signs as ordered; Observe resident for any signs or symptoms of malfunctioning Pacemaker (i.e.: Shortness of breath, dizziness, light headedness, fainting, chest pain, etc.) and report; Notify Physician as indicated.

    
    

22. Review of Resident #10's Clinical Record revealed no Physician's order for routine vital sign assessments. Review of the Nurses notes dated 2/10/09 through 3/3/09 reveal the following documentation of vital signs:

    1. 2/10/09 9:30 PM Upon arrival to Resident's room, found to be unresponsive, pupils non reactive, decreased heart rate. Pulse 22, Respirations 14, Blood pressure 70/60, oxygen saturation 99 % on room air. 911 call placed at 9:35 PM. 9:50 PM, Paramedics at facility.· 10:00 PM. Physician notified, order to transfer to ER. Resident left facility. with Paramedics to

       Hospital. transfer.

       10:30 PM:

       
       

       b. 2/17/09

       Residents family member notified of

       
       

       Readmitted from Hospital. Resident

       
       

       states: "be careful with me." Oxygen Saturation 99%. No

       
       

       documentation respirations.

       of blood pressure, pulse, temperature or

       c. 2/18/09, 2/19/09, and 2/20/09 vital signs include pulse, respirations, blood pressure and temperature within normal limits.

       1. No documentation of any vital signs on 2/21, 2/22, 2/23, or 2/24/09.

       2. 2/24 and 2/15/09 only temperature assessed.

          
          

       3. No documentation of any vital signs 2/26, 27, 2/28, 3/1 or 3/2/09.

          
          

       4. 3/2/09 11:00 AM. Refused breakfast with 2 attempts diabetic given with good results. Respirations unlabored, no distress.

23. An interview was conducted on 3/4/09 at 10:05 AM with the Unit Manager who was present when Resident #10 was found to have a change in condition. The Unit Manager was asked to describe what occurred.

    
    

    She stated that she had "just had a conversation with Resident #10 before the Surveyor walked up to the Nursing Desk. The Resident had stated, 'I want to go home to my maker, help me Jesus.' The Residents family is involved, so I called the Social Worker to let them know what the resident said. I didn't see a clinical change in his/her condition. The LPN told me that the resident was asleep. I instructed the LPN to take the resident to bed and get his/her vital signs. I then went on to something else. I expected the LPN to do as I instructed. I went into the Day Room to help feed the other residents. I saw the LPN move him/her (the resident) past the Medication Cart which was in front of the Nursing Desk. She did not follow the (Nursing) standard of care by immediately assessing the resident. She moved him/her just far enough so I couldn't see him/her. She should have checked her pulse, respiration, blood pressure and blood sugar and. called 911 immediately. I could not believe she left him/her in the room alone. Remember when I came to the room and asked you where she (the LPN) was? I left and called 911 myself. She has done this before."

    
    

24. The Surveyor conducted a side by side review of the Clinical Record of Resident #10. The DON confirmed that although the resident had a similar episode in February, the resident's vital signs were not monitored. The DON confirmed that the

    
    

    facility failed to monitor the vital signs of Resident #10,

    
    

    whose known history included a recent Pacemaker malfunction.

    
    

25. The DON confirmed that vital sig s should be routinely

    
    

    conducted on residents with similar clinical conditions to Resident #10 and care planned as well.

26. The DON confirmed that Resident #10 did not receive

    .,

    ordered medications for high blood pressure, pain and a urinary tract infection on 3/1, 3/2 and 3/3/09 due to the failure of the Nurse to transcribe physician orders from the February Medication Administration Record to the March Medication Administration Record. When asked if the failure to administer the ordered medications could have caused the change in Resident #l0's condition, the DON did not respond.

27. The Surveyor interviewed the Chief Nursing Officer

    
    

    (CNO) of the Hospital where Resident #10 was transferred to on 3/3/09 on 3/6/09 at 4:38 PM. The CNO stated that a review of Resident #l0's Clinical Record revealed that the resident had a pulse of 122 on arrival to the Emergency Room and was in Atrial Fibrillation. The resident was admitted to the Intensive Care Unit artd placed on an intravenous drip to control the irregular heart rate. The resident's admitting diagnosis included Congestive Heart Failure with bilateral pleural effusions and Atrial Fibrillation.

    
    

28. On 3/5/09, the resident's condition stabilized and he/she will be transferred back to the (SNF) facility today." Resident #9

29. A review of the Clinical Record of Resident #9 reveals Physician orders for the following pain medications for a diagnosis of Chronic Pain: Methadone 5mg by mouth three times a day; Tramadol 50 mg at AM and PM.; Tramadol 100 mg at bedtime.

30. Review of the Minimum Data Set (MDS) dated 10/30/08 and 2/4/09 reveals that the resident was coded as having no pain. The Surveyor conducted an interview with the MDS Coordinator on 3/4/09 at 11:30 AM. The Surveyor asked how the resident could be coded as having no pain, but was receiving three scheduled medications for pain. The MDS Coordinator stated, "his pain management must be effective."

31. Review of the Clinical Record revealed no documentation of any pain assessments being conducted on the resident. The Medication Nurse was asked if pain assessments are routinely conducted on residents who receive regularly scheduled pain medications. The Nurse stated, "We only do Pain Assessments on residents who receive PRN medications, not those who get them on a regular basis." The Surveyor asked how the facility staff knows if a patient's pain medication is effective. The Nurse stated the only way we know is if they ask for a PRN dose, we don't monitor regularly scheduled medications.

    
    

32. Review of the Consultant Pharmacist recommendations for Resident # 9 dated 1/23/09 reveals the recommendation, "Please consi._der periodic pain assessments while resident is receiving the following analgesics Ultram (Tramadol) Methadone and Lortab. The use of two or more analgesics in a resident may be a sign of poor pain control. The Physician responded to the recommendation by discontinuing the order for Lortab. No pain assessments were documented in the Clinical Record of Resident

    #9 in January, February and through the date of the Survey in

    
    

    March.

    
    

33. Review of the facility Discomfort and Pain Identification Plan of Care did not reveal monitoring of the residents response to medications to be an identified intervention. An interview was conducted with the DON on the afternoon of 3/4/09. The DON stated that she was unaware that facility staff do not routinely monitor or conduct pain assessments of residents who receive scheduled pain medications and that ongoing monitoring should be part of the Care Plan for a resident with Chronic Pain.

34. Resident #2 was admitted to the facility on 11/25/08 and re-admitted 2/25/09 with pertinent diagnoses including morbid obesity, congestive heart failure (CHF) and lymphedema (blockage of the lymph vessels).

    
    

35. During multiple observations and interviews conducted with the resident from 3/3/09 through 3/5/09, the surveyor observed the resident in bed consuming weight-reducing meals, receiving multiple physical therapy treatments,· writing letters and making arts and crafts. In all observations the resident was talkative and positive and accommodating in demeanor.

36. The resident spoke of his/her desire and steps taken to lose weight, and despite his/her heart and breathing problems, to increase his/her physical abilities so he/she could return home. Interviews also revealed frequent experiences with pain and discomfort to his/her legs and knees during his/her stay at the facility, as well as his/her long history of living with lymphedema and the attempts he/she made to obtain and use therapy and devices to control the condition. He/she recalled how after leaving the clinic with new leg wraps, the wraps would fall down by the time he/she got to the bus stop, and he/she would not be able to pull them up or replace them by him/herself.

37. During interviews held from 3/3/09 through 3/5/09 the

    
    

    resident stated the lymphedema causes him/her to be in a constant state of moderate pain, stating, "It feels like someone is scratching on my bones."He/she stated that lately he/she

    experiences "extreme pain and discomfort coming from my knees,

    
    

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    which knee and how bad it is depends on which leg is more swollen at the time."

38. When asked, the resident stated he/she has told facility staff· about past treatments which helped him/her deal with the condition but is told the facility does not have staff· that is certified in those treatments, so he/she gets Percocet on an as-needed basis.

39. The resident also stated he/she used to walk around the facility behind his/her wheelchair but since his/her hospital visit for pneumonia (2/19/09-2/25/09), being on oxygen

    24 hours a day, and the pain in his/her legs, he/she has not been able to get out of bed. He/she added that a fall from his/her bed in late January also makes him/her uncomfortable about getting out of bed because it causes severe, long-term pain and it takes a long time to get back to normal.

40. Review of the resident's clinical record reveals physician Progress Notes dated 2/26/09 and 3/4/09 which document lymphedema to· the lower extremities; a Podiatry consult documents the presence of lymphedema in both legs; a letter to the facility's Director of Nursing dated 2/3/09 from the resident's Psychologist includes reference to the resident's lymphedema pain and details symptoms experienced by the resident and asks the facility if "a pain management physician or

    
    

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    specialist consultant is available to help better manage and/or eliminate [resident's] pain."

41. Review of the resident's Nurses Notes for the period 11/28/08 through 3/3/09 reveal one entry dated 11/28/08 which appears to be a physician's history and summary which references lymphedema twice, at the beginning as a diagnosis and in the summary action plan which states "Lymphedema - continue to monitor". There is no other documentation or reference to lymphedema in the rest of the Nurses Notes.

42. Record review also reveals a 2/25/09 Nursing Data Collection form which documents the resident's admitting diagnoses as "CHF, morbid obesity, HTN (high blood pressure) and Steven-Johnson Syndrome". The Fall section was left blank. The Pain section has Reports pain? as 'Yes' but sections titled Location of pain, Severity of pain, Diagnosis supports likelihood of pain, and Observed pain behaviors were all left blank. There is no reference to lymphedema on the form.

43. Review of the resident's initial care plan and all individual care plans reveal no documentation of or reference to lymphedema.

44. Review of the resident's 12/2/08 Minimum Data Set in the section titled Disease Diagnoses reveals no documentation of the lymphedema under Item 3 titled Other current or more detailed diagnoses and ICD-9 codes. This section allows space

    19

    
    

    for five additional diagnoses and four diagnoses were listed in the section, but not lymphedema.

45. Review of the resident's Pain Intervention Sheet documents the form to contain the resident's room number but no other data has been recorded on it.

46. Further review of the resident's Nurses Notes dated 11/28/08 through 3/3/09 (119 days which excludes a 6-day hospital stay) documents 32 notes which state the resident complained of and received medication for pain (two tabs of Percocet 5 milligrams combined with 325 milligrams of Tylenol).

47. The Nurses Notes also document three occasions of

    
    

    nursing staff wrapping the resident's feet in ace bandages at bed time.

48. An interview on 3/4/09 at 3:10 PM, the North Wing Unit

    
    

    Manager stated the resident had orders for occupational and physical therapy evaluations and the physical therapy department would have assessed the lymphedema condition and referred the surveyor to the Physical Therapy department for more information. She confirmed there was no additional information or documentation available for review other than what was already reviewed in the resident's record.

49. An interview on 3/4/09 at 3:55 PM after reviewing the resident's record, a Physical Therapist stated the resident had been evaluated for general function therapy only, and presented

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    the surveyor with documentation showing the therapy treatments administered so far. She stated the facility did not have anyone certified to provide lymphed ma treatments and added the resident had a long history of lymphedema and had been non­ compliant with prior treatments as reasons for not addressing the resident's lymphedema. She also stated she had a conversation with the Director of Physical Therapy earlier that week about pursuing access to lymphedema treatments but the Director was on vacation so nothing was currently being pursued in that regard.

50. She further confirmed there was no additional information or documentation available for review.

51. Resident #17 was admitted to the facility on 2/26/09 after undergoing surgery to repair a fractured hip after a fall at home. The resident had three incision wounds to his/her right hip, upper thigh and knee and was receiving physical and occupational therapy as part of his/her rehabilitation. The resident was alert and oriented and able to make his/her needs known.

52. On 3/3/09 at 9:10 AM during the initial tour of the facility's North Wing, the resident was interviewed in his/her room. The resident explained why he/she was at the facility. When asked how he/she was doing that day, the resident responded he/she was in pain. When asked if he/she was receiving

    
    

    medication for the pain, the resident responded, "They give me Tylenol but I don't understand why they can't give me what was ordered."

53. An interview on 3/5/09 at 1:05 PM, the resident stated he/she is normally very tolerant of pain but since the surgery, he/she experiences pain daily, especially after receiving therapy, and described the pain to usually be a '6' on a scale of 1-10, 10 being the worst pain. The resident stated he/she has no appetite as a result of the constant pain, but has been told he/she is past the point of receiving pain medication on a routine basis, and has to ask every time.

54. Review of the resident's clinical record revealed the following:

    1. A 2/27/09 physician's order for one tablet of Vicodin ES (pain medication) to be administered every four hours as needed for pain, and a 3/2/09 physician's order which change the Vicodin order to an order for one tablet of Darvocet 100 every four hours as needed for pain.

    2. An Initial Care PlFn which documents in the section titled Pain Management that severity of pain is to be determined by: a scale of 0-5; resident report; and observe for side effects of pain medication.

       
       

    3. A Pain Intervention Flowsheet which was left blank except for the resident's name, room number and physician's name.

55. Progress Notes for 2/26/09, 2/28/09 and 3/2/09 which document the resident complained of pain. The resident's Medication Records for February and March 2009 reveal no documentation the Vicodin was administered from 2/26/09 through 3/2/09, and the Darvocet was not administered until 3/4/09, two days after it was ordered.

56. Progress Notes dated ·2/28/09 which documents the resident received Tylenol for pain when there is no documentation of a physician's order for Tylenol, nor is there documentation on the resident's February 2009 Medication Record that it was administered; and a Progress Note dated 3/2/09 documents "pain meds as ordered" but the resident's March 2009 Medication Record reveals no documentation that pain medication was administered on that date.

57. An interview on 3/5/09 at 1:25 PM, the North Wing Unit Manager was asked about the lack of pain medication administered to the resident. She stated she believed it was related to the resident's allergies and cited Progress Notes which state the resident denied pain. She stated she did not know why the Darvocet was not administered when ordered. She acknowledged the resident record should have documented any incidents of pain and

    
    

    any interventions or approaches used and stated she would speak to staff regarding same.

58. When asked about the administration of a medication not ordered by a physician she stated, "It was just Tylenol, but technically it should have been on the doctor's orders." She further confirmed there was no additional information or documentation available for review.

59. Based on the foregoing facts, Wood Lake Nursing and Rehabilitation Center violated Section 400.022(1) (1), Florida Statutes, herein classified as an isolated Class II violation purs., - to Section 400.23(8), Florida Statutes (2008), which carries an assessed fine of $2,500.00. This also gives rise to conditional licensure status pursuant to Section 400.23(7)(b), Florida Statutes (2008).

DISPLAY OF LICENSE

Pursuant to Section 400.25(7), Florida Statutes (2008), Wood Lake Nursing and Rehabilitation Center shall post the license in a prominent place that is clear and unobstructed public view at or near the place where residents are being admitted to the facility.

The conditional License is attached hereto as Exhibit "A"

EXHIBIT "A"

Conditional License

License# SNF13390962; Certificate No.: 15745

Effective date: 03/05/2009 Expiration date: 06/30/2011

Standard License

License# SNF13390962; Certificate No.: 15747

Effective date: 04/15/2009 Expiration date: 06/30/2011

PRAYER FOR RELIEF

WHEREFORE, the Petitioner, State of Florida Agency for Health Care Administration requests the following relief:

1. Make factual and legal findings in favor of the Agency on Count I.

2. Assess against Wood Lake Nursing and Rehabilitation

Center a conditional license in accordance with Section 400.23(7), Florida Statutes.

1. Assess costs related to the investigation and

   
   

   prosecution of this matter, if applicable.

   
   

2. Grant such other relief as the 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 (2008). 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 the Agency C1erk, Agency £or

Health Care Administration, 2727 Mahan Drive, MS #3,

Tallahassee, Florida 32308.

RESPONDENT IS FURTHER NOTIFIED THAT FAILURE TO RECEIVE A REQUEST A HEARING WITHIN TWENTY-ONE (21) DAYS OF RECEIPT OF THIS COMPLAINT, PURSUANT TO THE ATTACHED ELECTION OF RIGHTS, WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY.

IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER

ll!-A--0) ·<q .. r odi..1- - -:.. =­

·'} I) .

>

Alba M. R riguez, E;.

Fla. Bar No.: 0880175

Assistant General Counsel Agency for Health Care. Administration

8350 N.W. 52 Terrace - #103

Miami, Florida 33166

Copies furnished to:

Arlene Mayo-Davis Field Office Manager

Agency for Health Care Administration 5150 Linton Blvd. - Suite 500

Delray Beach, Florida 33483 (U.S. Mail)

Long Term Care Program Office

Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, Florida 32308 (Interoffice Mail)

Finance and Accounting

Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #14

Tallahassee, Florida 32308 (Interoffice Mail)

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Amin Sanaia, Administrator, Wood Lake Nursing and Rehabilitation Center, 6414 13t h Road South, West Palm Beach, Florida 33415; Corporation Service Company, 1201

Hays Street, Tallahassee, Flori'da 32301 June, 2009.

on th·is

1w1, -f

uay of

Alba M. Rodtig

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

RE: Wood Lake Health Care Associates, LLC d/b/a Wood Lake Nursing and Rehabilitation Center

AHCA No.: 2009003690

AHCA No.: 2009003691

ELECTION OF RIGHTS

This Election of Rights fonn is attached to a proposed action by the Agency for Health Care Admini tration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint.

Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice oflntent to Impose a Late Fee, Notice oflntent to Impose a Late Fine or Administrative Complaint.

If your Election of Rights with your selected option is not received by AHCA within twenty­ one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency's proposed action and a final order will be issued.

(Please use this fonn unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.)

PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS:

Agency for Health Care Administration Attention: Agency Clerk

2727 Mahan Drive, Mail Stop #3

Tallahassee, Florida 32308.

Phone: 850-922-5873 Fax: 850-921-0158.

PLEASE SELECT ONLY I OF THESE 3 OPTIONS

OPTION ONE (I) Iadmit to the allegations of facts and law contained in the Notice

of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action.

OPTION TWO (2) I admit to the allegations of facts contained in the Notice of Intent

to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced.

OPTION THREE (3) I dispute the allegations of fact contained in the Notice of Intent

to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings.

PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a fonnal hearing before

the Division of Administrative 1 .rings under Section 120.57(1), Floril. Statutes. It must be rec iveci by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain:

1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any.

2. The file number of the proposed action.

3. A statement of when you received notice of the Agency's proposed action.

4. A statement of all disputed issues of material fact. If there are none, you must state that there are none.

Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees.

License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number:

Contact person: _

Name Title

Address: Street and number City Zip Code

Telephone No. Fax No. Email(optional) _

I hereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above.

Signed: Date:

Print Name: Title:

Late fee/fine/AC

CERTIFICATE#: 15745

State of Florida

LICENSE#: SNF13390962

AGENCY FOR HEALTH CARE ADMINISTRATION

DIVISION OF HEALTH QUALITY ASSURANCE

NURSING HOME

CONDITIONAL

This is to confirm that WOOD LAKE HEALTH CARE ASSOCIATES, LLC has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is authorized to operate the following:

WOOD LAKE NURSING AND REHABILITATION CENTER 6414 13TH ROAD SOUTH

WEST PALM BEACH, FL 33415 TOTAL: 120 BEDS

STATUS CHANGE

ACTION EFFECTIVE DATE: 03/05/2009 LICENSE EXPIRATION DATE: 06/30/2011

, Division of Health Quality Assurance

CERTIFICATE#: 15747 LICENSE#: SNF13390962

State of Florida

AGENCY FOR HEALTH CARE ADMINISTRATION

DIVISION OF HEALTH QUALITY ASSURANCE

NURSING HOME

STANDARD

This is to confirm that WOOD LAKE HEALTH CARE ASSOCIATES, LLC has complied with the rules and regulations adopted by the State of Florida, Agency For Health Care Administration, authorized in Chapter 400, Part II, Florida Statutes, and as the licensee is

.:,_ authorized to operate the following:

WOOD LAKE NURSING AND REHABILITATION CENTER 6414 13TH ROAD SOUTH

WEST PALM BEACH FL 33415 TOTAL: 120 BEDS

STATUS CHANGE

ACTION EFFECTIVE DATE: 04/15/2009 LICENSE EXPIRATION DATE: 06/30/2011

ek

,Division of Health Quality Assurance

STATE OF FLORIDA

AGENCY FOR HEALTH CARE ADMINISTRATION

STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION,

.Petitioner,

v.

WOOD LAKE HEALTH CARE ASSOCIATES, LLC d/b/a WOOD LAKE NURSING AND REHABILITATION CENTER,

AHCA No.: AHCA No.: DOAH No.:

2009003690

20090036191

09-3737 9'1J

Respondent.

/

SETTLEMENT AGREEMENT

Petitioner, State of Florida, Agency for Health Care Administration (hereinafter the "Agency"), through its undersigned representatives, and Respondent, Wood Lake Health Care Associates, LLC d/b/a Wood Lake Nursing and Rehabilitation Center (hereinafter "Respondent"), pursuant to Section 120.57(4), Florida Statutes, each individually, a "party," collectively as "parties," hereby enter into this Settlement Agreement ("Agreement") and agree as follows:

WHEREAS, Respondent is a skilled nursing facility licensed pursuant to Chapters 400, Part II, and 408 Part II, Florida Statutes, Section 20.42, Florida Statutes, and Chapter

59A-4, Florida Administrat· d

EXHIBIT

I .a,

WHEREAS, the Agency has jurisdiction by virtue of being the regulatory and licensing authority over Respondent, pursuant to Chapter 400, Part II, Florida Statutes; and

WHEREAS, the Agency served Respondent with an administrative complaint on or about June 27, 2009, notifying the Respondent of its intent to impose administrative fines in the amount of $2,500.00 and assign a conditional licensure status commencing March 5, 2009 and ending April 14, 2009; and

WHEREAS, Respondent requested a formal administrative proceeding; and

WHEREAS, the parties have negotiated and agreed that the

best interest of all the parties will be served by a settlement of this proceeding; and

NOW THEREFORE, in consideration of the mutual promises and recitals herein, the parties intending to be legally bound, agree as follows:

1. All recitals herein are true and correct and are expressly incorporated herein.

2. Both parties agree that the "whereas" clauses incorporated herein are binding findings of the parties.

3. Upon full execution of this Agreement, Respondent agrees to waive any and all appeals and proceedings to which it may be entitled including, but not limited to, an informal

   
   

   proceeding under Subsection 120.57(2), Florida Statutes, a formal proceeding under Subsection 120.57(1), Florida Statutes, appeals under Section 120.68, Florida Statutes; and declaratory and all writs of relief in any court or quasi­ court of competent jurisdiction; and agrees to waive compliance with the form of the Final Order (findings of fact and conclusions of law) to which it may be entitled, provided, however, that no agreement herein shall be deemed a waiver by either party of its right to judicial enforcement of this Agreement.

4. Upon full execution of this Agreement, Respondent agrees to pay $1,875.00 to the Agency within thirty (30) days of the entry of the Final Order. Respondent accepts the assignment of conditional licensure status commencing March 5, 2009 and ending April 14, 2009.

5. Venue for any action brought to enforce the terms of this Agreement or the Final Order entered pursuant hereto shall lie in Circuit Court in Leon County, Florida.

6. By executing this Agreement, Respondent does not admit the allegations set forth in the Administrative Complaint, but recognizes that the Agency continues in good faith to assert the validity of these allegations. This agreement shall not preclude the Agency from (a) imposing or increasing any penalty against Respondent for any deficiency

   
   

   identified in a future survey of Respondent, (b) using the deficiency from the survey indentified in the Administrative Complaint in the future to establish a demonstrated pattern of deficient performance for licensure purposes. Should the Agency take any future action against the Respondent's license based upon the allegations set forth in the Administrative Complaint, however, Respondent retains the right to challenge any such future Agency action. In addition, this Agreement shall not preclude or estop any federal, other state, or local agency from taking or maintaining any action against Respondent based upon, in whole or in part, the allegations set forth in the Administrative Complaint.

7. Upon full execution of this Agreement, the Agency shall enter a Final Order adopting and incorporating the terms of this Agreement and closing the above-styled case.

8. Each party shall bear its own costs and attorney's fees.

This Agreement shall become effective on the date upon which it is fully executed by all the parties.

1. Respondent for itself and for its related or resulting organizations, its successors or transferees, attorneys, heirs, and executors or administrators, does hereby discharge the State of Florida, Agency for Health Care Administration, and its agents, representatives, and attorneys

   
   

   of and from all claims, demands, actions, causes of action, suits, damages, losses, and expenses, of any and every nature whatsoever, arising out of or in any way related to this matter and the Agency's actions, including, but not limited to, any claims that were or may be asserted in any federal or state court or administrative forum, including any claims arising out of this agreement, by or on behalf of Respondent or related facilities.

2. This Agreement is binding upon all parties herein and those identified in paragraph ten (10) of this Agreement.

3. In the event that Respondent was a Medicaid provider at the subject time of the occurrences alleged in the complaint herein, this settlement does not prevent the Agency from seeking Medicaid overpayments related to the subject issues or from imposing any sanctions pursuant to Rule 59G- 9.070, Florida Administrative Code.

4. Respondent agrees that if any funds to be paid under this agreement to the Agency are not paid within thirty-one

   (31) days of entry of the Final Order in this matter, the Agency may deduct the amounts assessed against Respondent in the Final Order, or any portion thereof, owed by Respondent to the Agency from any present or future funds owed to Respondent by the Agency, and that the Agency shall hold a lien against

   
   

   present and future funds owed to Respondent by the Agency for said amounts until paid.

5. The undersigned have read and understand this Agreement and have the authority to bind their respective principals to it.

6. This Agreement contains and incorporates the entire understandings and agreements of the parties.

7. This Agreement supersedes any prior oral or written agreements between the parties.

8. This Agreement may not be amended except in writing.

   
   

   Any attempted assignment of this Agreement shall be void.

   
   

9. All parties agree that an electronic or facsimile signature suffices for an original signature.

THIS PORTION OF THE PAGE LEFT BLANK DELIBERATELY

The following representatives hereby acknowledge that they are duly authorized to enter into this Agreement.

Elizan

Anna Small

....,

Deputy ecretary

Divisi n of Health Quality Assurance.

Agency for Health Care Administration

2727 Mahan Drive

Tallahassee, Florida 32308 Dated:

Ju in enior, Esq. General Counsel

Agency for Health Care Administration

2727 Mahan Drive

Tallahassee, Florida 32308

Attorney for Respondent Broad and Cassel

215 South Monroe Street Suite 400

Tallahassee, Florida 32302

Dated:

ilih-a,J Ro toa

Alba M. Rod ez,\..E d-

Assistant General Counsel Agency for Health Care Administration

8350 N.W. 52 Terrace - #103

Miami, Florida 33166

Dated: Dated:

Docket for Case No: 09-003737

Orders for Case No: 09-003737