STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCANos. 2010005527 (Fines) 2010005529 (Cond.) WILLISTON REHABILITATION AND NURSING CENTER, LLC, d/b/a WILLISTON REHABILITATION AND NURSING CENTER, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency’”), by and through the undersigned counsel, and files this Administrative Complaint against WILLISTON REHABILITATION AND NURSING CENTER, LLC, d/b/a Williston Rehabilitation and Nursing Center (hereinafter “Respondent’’), pursuant to §§120.569 and 120.57 Florida Statutes (2009), and alleges: NATURE OF THE ACTION This is an action to impose an administrative fine of ten thousand dollars ($10,000) and a survey fee of six thousand dollars ($6,000), for a total assessment of sixteen thousand dollars ($16,000.00), based upon the citation of one (1) Class I deficiency pursuant to §§400.102(1), Florida Statutes (2009). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing May 11, 2010 and ending May 27, 2010. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60, Florida Statutes, Chapter 400, Part IL and Chapter 408, Part II, Florida Statutes (2009), and Chapter 59A-4, Florida Filed June 24, 2010 1:03 PM Division of Administrative Hearings. Administrative Code. 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. 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 180-bed nursing home, located at 300 NW 1° Avenue, Williston, Florida 32696, and is licensed as a skilled nursing facility (license number 1381096). 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 (Tag N216) 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. Pursuant to §400.102, Florida Statutes (2009), in addition to the grounds listed in part II of chapter 408, any of the following conditions shall be grounds for action by the agency against a licensee: (1) An intentional or negligent act materially affecting the health or safety of residents of the facility; 8. The Agency conducted an unannounced complaint survey, CCR #2010004561, starting May 11, 2010 and ending May 12, 2010. 9. Based on record review and interview, the facility failed to provide appropriate care and services to (1 of 5) (#1) residents sampled by failing to identify and accurately report changing health conditions to the physician, and assess, care plan, and treat a sacral wound. 10. That the failure of the facility to identify changing health conditions in the resident and promptly notify the physician caused an immediate threat to the health of the resident that resulted in a delay of transportation to the hospital and further caused the resident to reccive a contraindicated treatment. Moreover, this failure resulted in an undocumented and untreated sacral wound. 11. That a review of the nursing notes for resident number (#) one (1) revealed a nursing note dated 4/10/2010 at 2:00 PM that indicates that resident #1 was stable, alert and "oriented X3", and nonverbal. 12. That a review of resident #1's medication administration record (MAR) revealed an entry dated 4/20/2010 at 06:30 AM which documents an elevated blood glucose of 239 mg /dl. (Milligrams / deciliter). Review of the Nursing notes revealed no notations recorded for this day. 13. That continued review of resident #1's MAR revealed an entry dated 4/24/2010 at 06:30 AM which documents an elevated blood glucose of 324 mg/dl. Again, no notations are recorded in the nursing notes for this day. 14. That further review of the nurses’ notes revealed an entry dated 4/25/2010 at 10:30 PM (which is the next entry after the entry dated 4/10/10) documenting that the resident had blood in his/her urine and that a specimen was obtained for urinalyses. 15. That a review of the next entry in the nursing notes which was dated 4/26/2010 at 12:40 PM and completed by nurse (#1) revealed that the resident had poor skin turgor, was refusing meals, and that the physician was notified and had ordered an IV infusion (intravenous) of D5 1/2NS (dextrose 5 percent in 0.45 percent normal saline) at 125 ml/hr (milliliters / hour). 16. That the entry also revealed that the unit manager was made aware of the resident's condition. 17. That during an interview with the unit manager on 5/10/2010 at 3:15 PM, the unit manager stated that she had been working as a medication nurse and only briefly remembers the situation, the unit manager did not report the resident's condition to anyone in administration. 18. That during interview on 5/10/2010 at 4:30 PM with nurse #1, who placed the call to the physician, the nurse stated that the last blood glucose had not been completed during her “on duty" time and that the value had not been reviewed by her anytime during her shift nor did she report the elevated value to the physician when she informed him of resident 1's status on 4/26/2010 at 12:40PM. 19. That an interview with the physician on 5/10/2010 at 1:30PM revealed that he had been unaware that the resident's last legible recorded blood sugar was 324 mg /dl. 20. That a review of the nurse's notes dated 4/26/2010 and timed for 3:00 PM to 11:00 PM signed by nurse #2 revealed that an IV was started, the resident had a small amount of dark urine, that the resident was non-responsive, and that all medications were held. 21, That no notation was recorded that indicates that the physician was notified of the resident's significant change in condition. 22. That during an interview with the physician on 5/10/2010 at 1:30 PM, the physician stated that the TV had been ordered because the resident had not eaten and that he would not have used the dextrose solution if he had been notified of the resident's recent elevated blood glucose testing results. He further stated that if he had been notified that the resident was unresponsive that he would have ordered the resident sent out to the Emergency Room (ER) for evaluation. 23. That continued review of the nurse’s note entry dated 4/26/2010 and timed for 11:00 PM to 7:00 AM documented by nurse #2 indicates that the resident remained unresponsive. 24. That during an interview with nurse #2 on 5/10/2010 at 3:30 PM, she stated that resident #1 was unresponsive at change of shift at 3:00PM on 4/26/2010 and that nurse #1 was present when she (nurse #2) first observed resident #1 and that nurse #1 had indicated that the doctor was aware of the resident's condition. 25. That a review of the nursing note dated 4/27/2010 at 09:00 AM revealed that the resident was unresponsive, but again does not indicate that the physician was notified. 26. That the note does indicate that the resident's spouse was notified at this time. Interview with the resident's spouse on 5/11/2010 at 9:10 AM revealed that this was the first time she had been notified that the resident was unresponsive. 27. That a further review of the nursing notes dated 4/27/2010 and timed at 10:00 AM revealed that the physician and spouse were present in the facility and that the physician had ordered the resident transported to the ER for evaluation. 28. That a review of the resident's emergency room record at the acute care hospital where resident #1 was transported to revealed that the resident arrived and was not responsive to any attempted stimuli. 29. That the record indicated that the results of the blood glucose reported on 4/27/2010 at 1:45 PM was a critical value of 538 mg / dl, and that the resident received treatment and was admitted as an inpatient at the acute care facility. 30. That a review of the facility provided policy with the title " Change in a Resident's Condition or Status "| reveals that the " The nurse supervisor/charge nurse will notify the resident's Attending Physician or On-Call Physician when there has been: an accident or incident involving the resident, S SP a discovery of injuries of an unknown source; a reaction to medication; a 9 a significant change in the resident's physical/emotional/mental condition; a need to alter the resident medical treatment significantly; refusal of treatment or medications (i.e., two (2) or more consecutive times); a need to transfer the resident to a hospital/treatment center; rp m o a discharge without proper medical authority; and/or b. Instruction to notify the physician of changes in the resident's condition. " 31. That an interview with the Director of Nursing on 5/10/2010 at 1:30 PM revealed that he had been unaware that resident #1's physician was not contacted about the elevated blood glucose value or when the resident had become unresponsive prior to surveyor questioning. 32. That an interview with the administrator on 5/10/2010 at 4:15 PM reveals that she had been unaware that resident #1's physician was not contacted about the elevated blood glucose value or when the resident had become unresponsive prior to surveyor questioning. 33. That a review of the physician's orders for resident #1 revealed that at the time of transfer to the hospital on 4/27/2010 the resident had no current orders for the treatment of a sacral wound. 34. That a review of the care plan for resident #1 revealed no indication of a sacral wound and that it was last updated on 4/25/2010. 35. That a review of the nurses’ notes from 3/30/2010 to the time the resident was transferred to the hospital on 4/27/2010 reveals no mention of a sacral wound. 36. That an interview with the unit manager on 5/10/2010 at 10:45 AM revealed that all records concerning wound care for resident #1 would be in his/her chart in medical records. 37. That a continued review of resident #1's chart from medical records failed to reveal any documentation of a sacral wound from 3/30/2010-4/27/2010. 38. That a review of the medical record from the receiving hospital for resident #1 revealed that the resident had a stage IT (2) sacral wound upon initial assessment in the emergency room. 39. That a review of the initial skin assessment for resident number one upon admission as an inpatient reveals that a stage IT sacral wound of approximately 1 centimeter by 2 centimeters was present. 40. The above findings reflect Respondent’s failure to provide appropriate care and services, thus the Respondent’s actions constituted an isolated Class | deficiency, pursuant of § 400.23(8)(a), Florida Statutes(2009). 41. That a Class I deficiency is a deficiency that the agency determines presents a situation in which immediate corrective action is necessary because the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility. The condition or practice constituting a class I violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. A class I deficiency is subject to a civil penalty of $10,000 for an isolated deficiency, $12,500 for a patterned deficiency, and $15,000 for a widespread deficiency. The fine amount shall be doubled for each deficiency if the facility was previously cited for one or more class I or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine must be levied notwithstanding the correction of the deficiency. WHEREFORE, the Agency intends to impose an administrative fine in the amount of $10,000.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2009). COUNT - 42. The Agency re-alleges and incorporates paragraphs one (1) through five (5), and Count I of this Complaint as if fully set forth herein. 43, Based upon Respondent’s cited State Class I deficiency, it was not in substantial compliance at the time of the survey with criteria established under Part IT 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)(b), Florida Statutes (2009). WHEREFORE, the Agency intends to assign a conditional licensure status to Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(7), Florida Statutes (2009) commencing May 11, 2010 and ending May 27, 2010. COUNT Ul 44. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I, and II of this complaint as if fully set forth herein. 45. | Respondent has been cited for one (1) State Class I deficiency and therefore is subject to a six (6) month survey cycle for a period of two years and a survey fee of six thousand dollars ($6,000) pursuant to Section 400.19(3), Florida Statutes (2009). WHEREFORE, the Agency intends to impose a six (6) month survey cycle for a period of two years and impose a survey fee in the amount of six thousand dollars ($6,000.00) against Respondent, a skilled nursing facility in the State of Florida, pursuant to Section 400.19(3), Florida Statutes (2009). CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully requests that this court: (A) Make factual and legal findings in favor of the Agency on Count I, II and III; and (B) Recommend an administrative fine against Respondent in the amount of $10,000; and (C) Assign a conditional licensure status commencing May 11, 2010; and (D) Grant a six month survey cycle for a period of 2 years and a survey fee of $6,000; and (E) Grant all other general and equitable relief allowed by law; and (F) Assess attorney’s fees and costs. Respectfully submitted June / , 2010. Agency for Health Care Admin. 2727 Mahan Drive, MS #3 Tallahassee, Florida 32308 850.412-3640 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE ICERTIFY that a copy hereof has been furnished to Alan P. Cooper, Administrator, Williston Rehabilitation and Nursing Center, 300 NW 1* Avenue, Williston, Florida 32696, by US. Certified Mail, Return Receipt No. 7004 2890 0000 5526 9852 and to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301 by U. S. Mail on lune, 2010. | Oth SU. D. Carlton Enfinger (; U ce: Kris Mennella, FOM

Docket for Case No: 10-003708