STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. AHCA Nos. 2009006841 (Fimes) ; 2009006844 (Cond.) RIVERWOOD NURSING CENTER, LLC, d/b/a Glenwood Nursing Center, Respondent / ADMINISTRATIVE COMPLAINT COMES NOW the Agency for Health Care Administration (hereinafter “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against RIVERWOOD NURSING CENTER, LLC, d/b/a Glenwood Nursing Center (hereinafter “Respondent”), pursuant to §§120.569 and 120.57 Florida Statutes (2008), and alleges:. NATURE OF THE ACTION This is an action to impose an administrative fine of fifty thousand dollars ($50,000) and a survey fee of six thousand dollars ($6,000), for a total assessment of fifty-six thousand dollars ($56,000.00), based upon the citation of four (4) Class I deficiencies pursuant to §§400.102(1) and 400.23(8)(a), Florida Statutes (2008). Additionally, this is an action to change Respondent’s licensure status from Standard to Conditional commencing June 5, 2009 and ending July 4, 2009. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to §§ 120.60, Florida Statutes, Chapter 400, Part II and Chapter 408, Part II, Florida Statutes (2008), and Chapter S9A-4, Florida Administrative Code. 2. Venue lies pursuant to Rule 28-106.207, Florida Administrative Code. Filed July 28, 2010 1:59 PM Division of Administrative Hearings. 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 119-bed nursing home, located at 40 Acme Street, Jacksonville, Florida 32211, and is licensed as a skilled nursing facility (license number 1508095). 5. Respondent was at all times material hereto, a licensed nursing facility under the licensing authority of the Agency, and was required to comply with all applicable rules, and statutes. COUNT I 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5), as if fully set forth herein. 7. Pursuant to §415.102, Florida Statutes (2008), Florida law provides the following: (1) "Abuse" means any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health. Abuse includes acts and omissions. (7)(a) "Exploitation" means a person who: 1. Stands in a position of trust and confidence with a vulnerable adult and knowingly, by deception or intimidation, obtains or uses, or endeavors to obtain or use, a vulnerable adult's funds, assets, or property with the intent to temporarily or permanently deprive a vulnerable adult of the use, benefit, or possession of the funds, assets, or property for the benefit of someone other than the vulnerable adult; or 2. Knows or should know that the vulnerable adult lacks the capacity to consent, and obtains or uses, or endeavors to obtain or use, the vulnerable. adult's funds, assets, or property with the intent to temporarily or permanently deprive the vulnerable adult of the use, benefit, or possession of the funds, assets, or property for the benefit of someone other than the vulnerable adult. 8. The Agency conducted an unannounced licensure survey starting June 1, 2009 and ending June 5, 2009 of Respondent’s facility. 9. That based on resident record review, a review of facility provided documents entitled "Behavior Event Follow-Up" a review of the facility's policy and procedures for abuse, and resident and staff interviews, the facility failed to investigate for 14 of 14 reported incidents that involved 14 residents. 10. That one incident resulted in harm to one resident and the other 13 incidents were alleged resident to resident abuse that lacked investigation. ll. That the facility neglected to investigate an incident of resident on resident behavior that resulted in Resident #139 being pushed to the ground by Resident #117 on 5/24/09 resulting in a broken hip. 12. That Resident #117 was not reassessed or the care plan revised after the incident occurred. 13. That one resident, Resident #34, was identified as not having been reassessed or revised unsuccessful plans of care with specific interventions that required monitoring of the resident’s behaviors. 14. That three residents, Residents #139, #4 and #118, were identified as not receiving needed services, care, and protection to prevent mental anguish and fear for their safety after the incident resulting in harm occurred. 15. That a review of facility provided documents entitled "Behavior event Follow Up" revealed incidents of resident to resident physical aggression involving 9 additional residents, Residents #20, #137, #125, #40, #108, #145, #34, #105, and #41. 16. That the facility failed to provide regular in-service education for non-licensed staff for Alzheimer's Disease/Cognitive Impairment/Difficult Behaviors. These employees would be the direct care staff responsible for caring any and all residents. 17. That the facility failed to implement policies and procedures for staff training, prevention, investigation, and protection which has the potential to affect the safety and well- being of all residents residing in this facility. 18. That the failure to train all staff on behavior issues, prevent incidents through monitoring of residents’ behavior, investigate the incidents, and ensure the protection of all residents placed the residents in this facility in immediate jeopardy. Resident # 139 19. That an interview with Resident #139 who the facility and the surveyors identified as interviewable, on 6/1/09 at 11:59 am, in his/her room while in their bed, revealed the resident was afraid of living here at times. 20. That another interview with the resident on 6/4/09 at 2:40 PM revealed the resident is afraid of "the girl who pushed me down." This resident was later identified as Resident #117. 21. That a review of Resident #139's medical record revealed a nurse's note dated 5/24/09 at 3:30 PM. which read "resident was involved in altercation with another resident. Shoved to floor in bathroom. Upon assessment, resident complained (of) (r) hip pain, When helped to stand up unable to bear weight." 22. That a further review of the medical record revealed Resident #139 was hospitalized 5/24/09 for a right hip hemiarthroplasty, as his/her hip was broken. 23. That the resident was readmitted to the facility from the hospital on 5/26/09. Resident #118 24, That an interview with Resident #118 on 6/1/09 at 11:10 am, revealed the resident was afraid of Resident #117. 25. That Resident #118 revealed that Resident #117 "comes into his/her room at night" and that it had been reported to staff. 26. That another interview with Resident #118 on 6/4/09 at 9:20 am revealed that Resident #117 resided in the room next to him/her and that they share a bathroom between the 2 rooms. 27. That he/she further stated Resident #117 had hit him/her recently. He/she further stated "am certainly afraid of" him/ her. He/she "comes into my room at night and goes through my night stand taking what (he/she) wants." 28. That Resident #118 went on to say that he/she had confronted the resident once about coming into their room and Resident #117 hit him/her so now he/she pretends to be asleep when the resident entered his/her room. 29. That the resident further stated "I am deathly afraid of (him/her). 1 have told staff what (he/she) is doing. I'm desperately afraid of (him/her)". Resident #4 30. That an interview with the roommate of Resident #117, Resident #4, on 6/3/09 at 12:45 PM, revealed the resident was also afraid of Resident #117 and staff was aware of that. Resident #117 31. That observations of Resident #117 on 6/3/09 at 12:26 PM revealed the resident was walking the halls unescorted. 32. That Resident #117 was observed walking unescorted at 12:58 PM on 6/3/09 in and of out other resident rooms in the South hall. 33. That on 6/3/09 at 1:20 PM Resident #117 was observed at the end of the South hall at the door way of the smoking porch, yelling loudly and carrying a large stuffed bear and a bag of other stuffed animals in his/her arms. Staff were surrounding him/her and attempting to calm him/her. 34. That an interview with a nurse on 6/3/09 at 1:20 PM revealed the stuffed animals did not belong to the resident but actually belong to his/her roommate, Resident #4. She further stated that Resident #117 was going to throw them over the fence. 35. That the South wing nurse also stated that Resident #117 had been involuntarily sent for treatment due to aggressive behavior (State of Florida, Baker Act) at another nursing facility before admission to this facility. 36, That the staff did have knowledge of the resident's former aggressive behaviors. 37. That a review of the medical record of Resident #117 revealed the resident, who was noted as middle age, was admitted to the facility on 4/21/09. 38. That further review of the medical record revealed a nurse’s note dated 4/21/09 at 7:00 PM which stated "resident wandering in and out of other rooms verbally and physically aggressive with staff and other residents. 39. That further review of the nurse’s notes revealed on 5/15/09 at 8:00 PM "resident entered room #124 and into an altercation with the resident (residing in that room). Resident with left cheek red and stating that s/he had been hit in face by resident the of room." 40. That-even further review of the nurse’s note revealed a note written 5/24/09 at 3:30 PM which read "resident involved in altercation with another resident. S/he shoved the referenced resident (Resident #139) to the bathroom floor." 41, That no evidence could be found of any investigations for the above mentioned resident to resident possible allegations of abuses. 42. That on 6/3/09 at 3:13 PM an interview with the Abuse Prevention Coordinator and Risk Manager revealed no investigations were done for resident to resident aggression to determine if possible neglect occurred. Review of the facility provided Abuse investigations revealed no evidence that investigations were completed for resident to resident physical aggression. Resident # 34 43. That a review of the medical record of Resident #34 revealed the resident was admitted to the facility on 2/23/09 with a diagnosis of Bipolar Disorder, Schizophrenia, Psychosis, and Insomnia. | 44, That further review of the record revealed a nurse’s note dated 4/10/09 at 7:10 PM which read "CNA reported resident placed his/her foot and tripped another resident while in the back porch (smoking porch)." 45. That another nurse’s note dated 4/11/09 at 7:30 PM stated "Resident being aggressive toward other residents on smoking porch had to be brought back indoors." 46. That a nurse’s note dated 5/8/09 at 8:30 PM stated "Goes in and out of smoking porch, continues to push male resident." 47. That a nurse’s note dated 5/10/09 at 2:20 PM revealed "During breakfast he/she and another resident got into it, No injuries noted." 48. That a nurse’s note dated 5/15/09 at 5:45 PM read "Had been loud and screaming at CNA's and other residents while in the main dining room, attempted to hit a resident while s/he was ambulating between tables." 49. That a nurse’s note dated 5/26/09 read "Was reported by CNA that resident was physically and verbally aggressive with another resident while on smoking porch after supper." 50. That a review of facility provided documentation entitled "Behavior Event Followup" dated 6/3/09 had attached staff statement, "Staff was talking to UM and South 2 nurse. She heard a resident yell. She turned around and she was holding his/her right hand. She saw Resident #4 on the other side of the door leaning on it." This was in reference to an incident on the smoking porch with an unsampled resident and Resident #34, with Resident #34 purposely closing the door on the unsampled resident's hand according to an interview with the nurse on 6/4/09 at 4:30 PM. SI. That no evidence could be found that any of the above incidents of resident to resident physical aggression was investigated for possible staff neglect. 52. That on 6/3/09 at 3:13 PM an interview with the Abuse Prevention Coordinator and Risk Manager revealed no investigations were completed for resident to resident physical aggression to determine if possible neglect occurred. 53. That a review of the facility provided Abuse investigations revealed no evidence thorough investigations are done for resident to resident physical aggression. 54. That a review of facility provided documents entitled "Behavior event Follow Up", which was what the facility indicated they used to identify incidents, revealed incidences of resident to resident physical aggression involving 9 additional residents. 55. That in addition there was 1 observation of a resident involved in an incident of physical aggression that was not investigated by the facility: a. 12/17/08 - Resident #20 threw his/her mattress onto his/her sleeping roommate; b. 12/27/08 - Resident #137 hit his/her sleeping roommate in their room; c. 2/1/09 - Resident #125 was fighting with Resident #18 at the smoking door. First Aid was administered; d. 4/12/09 - Resident #40 struck another resident in the face, first aid administered to bleeding right cheek, in the smoking area; e. 5/16/09 - Resident #108 accused of hitting another resident in the face when the resident entered Resident #108's room; f. 5/19/09 - Resident #145 was "slapped" in face by a resident who entered his/her room; g. 6/3/09 - Resident #34 "purposely" closed smoking door on Resident #105's hand; and h. An observation on 6/3/09 at 1:53 PM revealed Resident #41 hitting another resident about the head and shoulders in front of the nurses’ station on the South Hall. Staff were informed of the observation immediately. As of 6/5/09 at 2:40 PM the facility had not interviewed the witness of the incident. 56. The above findings reflect Respondent’s failure to prevent abusive episodes, thus the Respondent’s actions constituted a Class I deficiency, pursuant of § 400.23(8)(a), Florida Statutes(2008). 57. 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 $12,500.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2008). COUNT I 58. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 59. Pursuant to §400.147(1), Florida Statutes (2008), Florida law provides the following: (1) Every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: (a) A designated person to serve as risk manager, who is responsible for implementation and oversight of the facility's risk management and quality assurance program as required by this section. . (b) A risk management and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. The risk management and quality assurance committee shall meet at least monthly. (c) Policies and procedures to implement the internal risk management and quality assurance program, which must include the investigation and analysis of the fréquency and causes of general categories and specific types of adverse incidents to residents. (d) The development and implementation of an incident reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report adverse incidents to the risk manager, or to his or her designee, within 3 business days after their occurrence. (ce) The development of appropriate measures to minimize the risk of adverse incidents to residents, including, but not limited to, education and training in.risk management and risk prevention for all nonphysician personnel, as follows: 1. Such education and training of all nonphysician personnel must be part of their initial orientation; and 2. At least 1 hour of such education and training must be provided annually for all nonphysician personnel of the licensed facility working in clinical areas and providing resident care. (f) The analysis of resident grievances that relate to resident care and the quality of clinical services. 60. The Agency conducted an unannounced licensure survey starting June 1, 2009 and ending June 5, 2009 of Respondent’s facility. 61. That based on observation, record review, staff and resident interview, the facility neglected to identify residents that were inclined to physically harm other residents, develop successful interventions to prevent occurrences plus reoccurrence and monitor the resident's behavior because of the likelihood that the residents could cause harm to other residents. The facility failed to reassess or revise unsuccessful plans of care with specific interventions for 2 of 38 sampled residents, Residents #34 and #117. In addition, the facility failed to provide needed services, care, and protection to prevent mental anguish and fear for their safety for 3 of 38 sampled residents, Residents #4, #139, and #118. 62. That the failure to identify aggressive residents and develop successful interventions and monitor those interventions for effectiveness and revise plans of care as needed has led to residents who have expressed that they have lived in fear and anguish. Fearfulness and anguish were expressed by residents when staff had knowledge of a resident's aggressive behaviors the facility failed to reassess and revise the residents’ plans of care. Other residents with aggressive behaviors were identified and there was a lack of plans of care to ensure that harm did not occur to other facility residents. 63. That the facility neglected to investigate an incident of resident on resident behavior that resulted in Resident #139 being pushed to the ground by Resident #117 on 5/24/09 resulting in a broken hip. The facility did not investigate the incident including calling the Medical Director nor the Psychiatrist to inform them of the incident and immediately putting into place plans to ensure that the harm, that occurred to Resident #139, did not happen again. The immediacy of the situation was realized on 6/3/09 through observations of a resident's aggressive behavior and when some staff stated they were not aware of how to care for that resident and others with aggressive behaviors. 64, That an interview with Resident #118 who resides in the room next to Resident #117 and Resident #4, who was the roommate of Resident #117, revealed that these residents lived in fear that the resident may come into their room and cause harm to them. 65. Immediate Jeopardy occurred on 5/24/09 when the resident sustained a hip fracture as a result of the aggressive behavior of another resident. The likelihood that resident to resident aggression could occur again was present from 5/24/09 until 6/3/09 when the Immediate Jeopardy was identified during the time of the recertification survey. Resident # 139 66. That an interview with Resident #139 who the facility and the surveyors identified as interviewable, on 6/1/09 at 11:59 am, in his/her room while in their bed, revealed the resident was afraid of living here at times. 67. That another interview with the resident on 6/4/09 at 2:40 PM revealed the resident was afraid of "the girl who pushed me down." This resident was later identified as Resident #117. 68. That a review of Resident #139's medical record revealed a nurse's note dated 5/24/09 at 3:30 PM which read "resident was involved in altercation with another resident. Shoved to floor in bathroom. Upon assessment, resident complained (of) (r) hip pain. When helped to stand up unable to bear weight." 69. That a further review of the medical record revealed Resident #139 was hospitalized 5/24/09 for a right hip hemiarthroplasty, as his/her hip was broken. 70. That the resident was readmitted to the facility from the hospital on 5/26/09. Resident #118 71. That an interview with Resident #118 on 6/1/09 at 11:10 am, revealed the resident was afraid of Resident #117. 72. That Resident #118 revealed that Resident #117 "comes into his/her room at night" and that it has been reported to staff. 73. That another interview with Resident #118 on 6/4/09 at 9:20 am revealed that Resident #117 resided in the room next to him/her and that they share a bathroom between the 2 rooms. 74. That he/she further stated Resident #117 had hit him/her recently. He/she further stated "am certainly afraid of" him/her. He/she "comes into my room at night and goes through my night stand taking what (he/she) wants." 75, That Resident #118 went_on to say that he/she had confronted the resident once about coming into their room and Resident #117 hit him/her so now he/she pretends to be asleep when the resident entered his/her room. 76. That the resident further stated "I am deathly afraid of (him/her). I have told staff what (he/she) is doing. I'm desperately afraid of (him/her)". Resident #4 77. That an interview with the roommate of Resident #117, Resident #4, on 6/3/09 at 12:45 PM, revealed the resident was also afraid of Resident #117 and staff was aware of that. Resident #117 78. That observations of Resident #117 on 6/3/09 at 12:26 PM revealed the resident was walking the halls unescorted. 79. That Resident #117 was observed walking unescorted at 12:58 PM on 6/3/09 in and of out other resident rooms in the South hall. 80. ‘That on 6/3/09 at 1:20 PM Resident #117 was observed at the end of the South hall at the door way of the smoking porch, yelling loudly and carrying a large stuffed bear and a bag of other stuffed animals in his/her arms. Staff were surrounding him/her and attempting to calm him/her. 81. That at 1:49 PM on 6/3/09 Resident #117 was observed walking the halls unescorted carrying the stuffed animals. An interview with a nurse on 6/3/09 at 1:20 PM revealed the stuffed animals did not belong to the resident; but actually belong to his/her roommate, Resident #4. She further stated that Resident #117 was going to throw them over the fence. The South wing nurse also stated that Resident #117 had been involuntarily sent for treatment due to aggressive behavior (State of Florida, Baker Act) ¢ at another nursing facility before admission to this facility. 82. That the staff did have knowledge of the resident's former aggressive behaviors. 83. That a review of the medical record of Resident #117 revealed the resident, who was noted as middle age, was admitted to the facility on 4/21/09. 84. That a further review of the medical record revealed a nurse’s note dated 4/21/09 at 7:00 PM which stated "resident wandering in and out of other rooms verbally and physically. aggressive with staff and other residents, 85. That a further review of the nurse’s notes revealed on 5/15/09 at 8:00 PM "resident entered room #124 and into an altercation with the resident (residing in that room). Resident with left cheek red and stating that s/he had been hit in face by resident the of room." 86. That even further a of the nurse’s note revealed a note written on 5/24/09 at 3:30 PM which read "resident involved in altercation with another resident. S/he shoved the referenced resident (Resident #139) to the bathroom floor." 87, That a review of the Minimum Data Set admission assessment dated 5/4/09 revealed that the resident was assessed as having long and short term memory concerns and as having moderately impaired decision making. 88. That the resident was also assessed as being physically and verbally abusive, socially inappropriate and being a wanderer. 89. That a review of Resident #117's care plan dated 5/11/09 revealed the resident was care planned for "becoming easily upset or angered, being verbally or physically aggressive, being socially inappropriate of roaming in other belongings, refusing care, wanders, delusions ". 90. That the approaches for these behaviors were the following: explain procedures, approach in a calm unhurried manner, validate feelings regarding delusions then redirect from subject, redirect him/her when he/she begin roaming in others belongings, monitor whereabouts frequently and redirect from unsafe areas and out of other resident rooms and away from exit doors, smile at him/her and encourage the resident to attend activities, provide touch therapy to help convey a sense of caring and calmness, if upset allow time to calm down and then . reapproach, explain that s/he can express his/her needs without being verbally or physically aggressive, explain importance of him/her cooperating with his/her care, administer medications per MD, and provide one on one visits regularly. 91. That no evidence could be found that the care plan was revised after the incidents of aggression on 5/15/09 and/or 5/24/09. 92. That a review of Resident #117's psychiatric consult dated 5/28/09 revealed the | psychiatrist had decreased the residents Ativan from 2mg, four times a day to 2mg, twice a day. 93. That an interview with the Psychiatric Physician Assistant (PA) on 6/4/09 at 9:11 am revealed the facility had never informed him of the incident involving Resident #117 on 5/24/09 and that another resident had their hip broken in the incident. 94. That the PA continued that he reduced medication as the resident appeared lethargic to him. He reiterated that "No one told me about the incident and they should have told me of such a major event." 95. That a psychiatric consult dated 6/4/09 revealed Xanax 2 mg, three times a day was ordered and Zyprexa was increased from 10 mg, twice daily to 15mg, twice daily. 96. That interviews with Certified Nursing Assistants (CNA) who may come in contact with Resident #117 revealed the staff were unaware of Resident #117's aggressive behaviors and the resident's individual plan of care that would give interventions as to care of the resident when the behaviors occurred: a. An interview with a 3-11 CNA working the North wing on 6/3/09 at 5:24 PM revealed the CNA had worked at the facility for 5 months and did not know who Resident#117 was or what behaviors he/she displays or his/her care plan for interventions; b. An interview with another CNA on the 3-11 shift at 5:26 PM on 6/3/09 in the South wing where Resident #117 lived, and the CNA stated he did not know Resident #117's behaviors or his/her care plan for interventions. ce. On 6/3/09 at 5:30 PM a CNA was observed sitting next to Resident #117 in his/her room. An interview with the CNA at this time revealed the CNA was not aware of care plan for behaviors and further stated Resident #117 was often one of her assigned residents. The staff member also stated she was assigned to sit with him/her due to his/her behaviors, but was not told what to do, other than stay with Resident #117. Resident #34 97. That a review of the medical record of Resident #34 revealed the resident was admitted to the facility on 2/23/09 with a diagnosis of Bipolar Disorder, Schizophrenia, Psychosis, and Insomnia. 98. That a further review of the record revealed a nurse’s note dated 4/10/09 at 7:10 PM which read "CNA reported resident placed his/her foot and tripped another resident while in the back porch (smoking porch)." 99. That another nurse’s note dated 4/11/09 at 7:30 PM stated "Resident being " aggressive toward other residents on smoking porch had to be brought back indoors." 100. That a nurse’s note dated 5/8/09 at 8:30 PM stated "Goes in and out of smoking porch, continues to push male resident." 01. That a nurse’s note dated 5/10/09 at 2:20 PM revealed "During breakfast he/she and another resident got into it, No injuries noted." 02. That a nurse’s note dated 5/15/09 at 5:45 PM read "Had been loud and screaming at CNA's and other residents while in the main dining room, attempted to hit a resident while s/he was ambulating between tables." 103. That a nurse’s note dated 5/26/09 read "Was reported by CNA that resident was physically and verbally aggressive with another resident while on smoking porch after supper." 104. That a review of facility provided documentation entitled "Behavior Event Follow- up" dated 6/3/09 had attached staff statement, "Staff was talking to UM and South 2 nurse. She heard a resident yell. She turned around and s/he was holding her right hand. She saw Resident #34 on the other side of the door leaning on it." This was in reference to an incident on the smoking porch with an unsampled resident and Resident #34, with Resident #34 purposely closing the door on the unsampled resident's hand according to an interview with the nurse on 6/4/09 at 4:30 PM. 105. That a further review of Resident #34's medical record revealed the resident had a care plan dated 3/12/09 for "Becomes easily upset with others, has history of yelling loudly, threatening others, trying to step on others toes." The following were the approaches for the behaviors: explain procedures, approach in a calm unhurried manner, explain to him/her that he/she does not have to yell to express his/her feeling, smile at him/her and encourage him/her to attend activities, provide touch therapy to help.convey a sense of caring and calmness, if upset allow time to calm down and then reapproach explain that he/she can express his/her needs without being physically aggressive, explain importance of his/her eating his/her meals and taking his/her supplements, monitor his/her interactions with other residents and then redirect if needed, redirect him/her if he/she is displaying socially inappropriate behaviors, administer medications per MD orders, provide one on one visits regularly. 106. That the plan was revised on 4/2/09 to include: staff to stay with resident until he/she calms down, house psych services will be notified if there was a change in his/her behavior. 107. That no revisions of care plan were found after incidents on 4/10/09, 4/11/09, 5/8/08, 5/10/09, 5/15/09, 5/26/09 or 6/3/09. There was no evidence the care plan for behaviors was reassessed for efficacy and to ensure other residents were safe from Resident #34 could be found. 108. That an interview on 6/4/09 at 2:00 PM with a CNA who had worked the smoking porch duty stated if Resident #34 had behaviors she was to report it to a nurse. The CNA was not aware of what care plan approaches were for the resident's aggressive behaviors. 109. That an interview with the smoking area supervisor on 6/4/09 at 2:12 PM revealed the supervisor knew Resident #34 but did not know what approaches to use with Resident #34 and would report behaviors to the nurse. 110. The above findings reflect Respondent’s failure to identify concerns and develop plans of action to address care and-service issues that impacted the health and safety of residents, thus the Respondent’s actions constituted a Class I deficiency, pursuant of § 400.23(8)(a), Florida Statutes (2008). 111. 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 $12,500.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 20 400.23(8)(a), Florida Statutes (2008). COUNT I 112. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 113. Pursuant to Fla. Admin. Code R. 59A-4.109(1), each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: (a) Physician’s orders, diagnosis, medical history, physical exam and rehabilitative or restorative potential. (b) A preliminary nursing evaluation with physician’s orders for immediate care, completed on admission. (c) A complete, comprehensive, accurate and reproducible assessment of each resident’s functional capacity which is standardized in the facility, and is completed within 14 days of the resident’s admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed promptly after a significant change in the resident’s physical or mental condition, 3. Revised as appropriate to assure the continued accuracy of the assessment. 114. The Agency conducted an unannounced licensure survey starting June 1, 2009 and ending June 5, 2009 of Respondent’s facility. 115. That based on observations, interviews and record review, the facility failed to revise interdisciplinary care plans for 1 of 38 sampled residents, Resident #117 who exhibited aggressive behaviors causing injury to another resident. 21 116. That immediate Jeopardy occurred on 5/24/09 when the Resident #139 sustained a hip fracture as a result of the aggressive behavior of Resident #117. 117. That no evidence could be found that the care plan was revised after the incident. The likelihood that resident to resident aggression could occur again was present from 5/24/09 until 6/3/09 when the Immediate Jeopardy was identified during the time of the recertification survey. 118. That in addition, the facility failed to address specific needs for 5 of 38 sampled residents, Residents #34, #125, #80, #103, and #65: behaviors; nutrition; medications; and the use of the least restrictive device. Resident #117 119. That a review of Resident #117's care plan dated 5/11/09 revealed the resident was care planned for "becoming easily upset or angered, being verbally or physically aggressive, being socially inappropriate of roaming in other belongings, refusing care, wanders, delusions ". 120. The approaches for these behaviors are the following: explain procedures, approach in a calm unhurried manner, validate feelings regarding delusions then redirect from subject, redirect him/her when he/she begin roaming in others belongings, monitor whereabouts frequently and redirect from unsafe areas and out of other resident rooms and away from exit doors, smile at him/her and encourage him/her to attend activities, provide touch therapy to help convey a sense of caring and calmness, if upset allow time to calm down and then reapproach, explain that he/she can express his/her needs without being verbally or physically aggressive, explain importance of his/her cooperating with his/her care, administer medications per MD, and provide one on one visits regularly. 22 121. That no evidence could be found that the care plan was revised after the incidents of aggression on 5/15/09 and/or 5/24/09. 122. That an interview with the MDS Coordinator on 6/3/09 at 9:32 am stated that if there was a needed change for resident care plans that she will either update/revise the care plans at the care plan meeting or nursing staff will revise/update the care plan after the care plan meeting. . 123. That staff stated that she had 119 care plans to complete/update and requires nursing staff's help in regards to keeping all care plans revised. 124, That an interview with the Assistant Director of Nursing (ADON) on 6/3/09 at 9:37 am who stated that the nurses update the care plans on the floor and if they do not then the ADON, unit manager or risk manager will update resident care plans. 125, That an interview with the Risk Manager 6/3/09 at 10:58 am who stated that the DON is responsible for updating/revising resident care plans and that she does not complete this task. Resident 434 126. That a review of Resident #34's medical record revealed the resident had a care plan dated 3/12/09 for "Becomes easily upset with others, has history of yelling loudly, threatening others, trying to step on others toes." 127. ‘That the following are the approaches for the behaviors: explain procedures, approach in a calm unhurried manner, explain to him/her that he/she does not have to yell to express his/her feeling, smile at him/her and encourage him/her to attend activities, provide touch therapy to help convey a sense of caring and calmness, if upset allow time to calm down and then reapproach explain that he/she can express his/her needs without being physically aggressive, 23 explain importance of his/her eating his/her meals and taking his/her supplements, monitor his/her interactions with other residents and then redirect if needed, redirect him/her if he/she is displaying socially inappropriate behaviors, administer medications per MD orders, provide one on one visits regularly. 128. . That the plan was revised 4/2/09 to include: staff to stay with resident until he/she calms down, House psych services will be notified if there is a change in his/her behavior. 129, That no revisions of the care plan were found after incidents on 4/10/09, 4/11/09, 5/8/08, 5/10/09, 5/15/09, 5/26/09 or 6/3/09. 130. That no evidence the care plan for behaviors was reassessed for efficacy and to ensure other residents were safe from Resident #34 could be found. 131. That an interview on 6/4/09 at 2:00 PM with a CNA who had worked the smoking porch duty stated if Resident #34 had behaviors she was to it report to the nurse. The CNA was not aware of what care plan approaches were for the resident's aggressive behaviors. 132. . That an interview with smoking area supervisor on 6/4/09 at 2:12 PM revealed the supervisor knew Resident #34 but did not know what approaches to use with Resident #34. Would report behavior to the nurse. Resident #125 133. That an observation of Resident #125 on 6/1/09 at 12:15 PM, in their room, revealed the resident sitting on their béd with a bedside table holding their lunch. The bunch included cooked spinach, a thick slice of ham, and sweet potatoes. The resident was observed to only eat the sweet potatoes. 24 134. That an interview with the resident on 6/1/09 at 12:16 PM revealed the resident does not eat meat and did not like the spinach, the resident further stated the kitchen was aware he/she did not eat meat. 135. That during this observation the resident ate only their sweet potatoes. No other foods were offered. 136. That'a review of staff's documentation on client's portion of food eaten for 6/1/09 lunch revealed the staff had marked "good". 137. That an observation on 6/2/09 at 12:45 PM of Resident #125 at lunch, in their room, revealed the resident was served Salisbury steak, baked potato, and beets. The resident was observed giving their Salisbury steak to another resident. Approximately 2 bites of the baked potato were eaten and the beets were untouched. 138. That an interview with the resident at 12:46 PM on 6/2/09, revealed the resident did not want the meat and gave it away, did not like beets, and that the potato wasn't cooked all the way so the resident could not eat it, 139, That when the resident's tray was removed, no other foods were offered. 140, That a review of staff's documentation on client's portion of food eaten for 6/1/09 lunch revealed the staff had marked "fair". . 141. That an observation of Resident #125's breakfast tray at 8:13 am on 6/3/09, when removed from the resident's room, revealed the resident had not eaten the eggs and ham bake, but had eaten the oatmeal and toast. 142. That a review of the resident's meal ticket for that meal revealed staff had recorded the resident ate 100% of the meal. 25 143. That a review of the resident's Quarterly Nutrition assessment dated 4/15/09 revealed no mention of the resident not eating meats. A review of the complete medical record revealed no mention of the resident not eating meat. 144, That an interview with the nurse on 6/1/09 at 12:30 PM revealed that the resident does not eat meat. 145. That an interview with the Certified Nursing Assistant (CNA) on 6/3/09 at 7:53 am revealed the resident rarely eats meat at lunch or breakfast. 146, That a review of the resident's care plan revealed a care plan for risk of weight loss dated 4/2/09. The care plan does not address the resident not eating meat or not eating much of their meal even though nursing staff are aware the resident refuses to eat offered meat at meals. Resident #80 147, That a review of Resident #80's care plan on 6/3/09 revealed care plan initial date of 8/26/08. Resident problem: at risk for signs/symptoms of side effects related to psychotropic medications, Ativan and Zoloft. 148, That a review of Resident #80's physician order sheet (POS) dated 9/17/08 revealed "discontinue Zoloft patient refusal." 149. That a review of Resident #80's medication administration record (MAR) dated 6/1/09 revealed, resident is not receiving Zoloft. Resident # 65 _ 150. That a review of Resident #65's care plan on 6/2/09 revealed a care plan with an initial date of 8/03/08. 151. That further review revealed resident problems: at risk for signs/symptoms of side effects related to psychotropic medications, Remeron, Zoloft, Zyprexa, Ability and Ativan. 26 152. That a review of Resident #65's MAR dated 6/1/09 revealed, resident was not receiving Abilify. . Resident #103 153. That observation of Resident #103 on 6/2/09 revealed the resident getting up and wandering around resident's room and into the hallway. A CNA came to assist the resident to get into his/her wheelchair. The resident was in the wheelchair for about 5 minutes and was trying to ambulate. The CNA then placed a soft waist belt around the resident who then propelled himself/herself down the hall in his/her wheelchair. 154. “That observation of Resident #103 on 6/3/09 after lunch sitting in the wheelchair with a soft lap belt positioned correctly. The resident was propelling himself/herself with his/her legs around his/her room. 155. | That an interview with the North wing nurse on 6/2/09 stated that the resident did not have a bed or chair alarm and that she cannot remember the resident ever having either item. 156. That a review of Resident #103's care plan on 6/2/09 revealed a care plan with the initial date of 6/23/08. 157. That further review revealed resident problem: at risk for falls related to blindness, poor balance, need for limited assist with transfers and ambulation, decreased cognitive awareness, and use of psychotropic medications, Ativan, Restoril, Zyprexa and Depakote. 158. That a review of Resident #103's MAR dated 6/1/09 revealed, resident is not receiving Restoril or Depakote, 159. That a review of Resident #103's care plan on 6/2/09 revealed care plan initial date 6/23/09. Review revealed resident approaches for falls; non-skid shoes, bed/chair alarm in place 27 at all times, call light to be kept within reach at all times, provide limited assist with transfers, ensure wheelchair is locked when patient is in it and soft waist belt. 160. That a review of Resident #103's activities of daily living functional/testorative assessment and progress dated 3/5/09 revealed; chair and bed alarm. 161. That a review of Resident #103's POS on 6/2/09 revealed no orders for bed and chair alarms. 162. The above findings reflect Respondent’s failure to identify concerns and develop plans of action to address care and service issues that impacted the health and safety of residents, thus the Respondent’s actions constituted a Class I deficiency, pursuant of § 400.23(8)(a), Florida Statutes (2008). 163. 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 J 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 ctvil 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 $12,500.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 28 400.23(8)(a), Florida Statutes (2008). COUNT IV 164. The Agency re-alleges and incorporates paragraphs one (1) through five (5) of this Complaint as if fully set forth herein. 165. Pursuant to §400.147(1), Florida Statutes (2008), every facility shall, as part of its administrative functions, establish an internal risk management and quality assurance program, the purpose of which is to assess resident care practices; review facility quality indicators, facility incident reports, deficiencies cited by the agency, and resident grievances; and develop plans of action to correct and respond quickly to identified quality deficiencies. The program must include: (b) A risk management and quality assurance committee consisting of the facility risk manager, the administrator, the director of nursing, the medical director, and at least three other members of the facility staff. The risk management and quality assurance committee shall meet at least monthly. 166. The Agency conducted an unannounced licensure survey starting June 1, 2009 and ending June 5, 2009 of Respondent’s facility. 167. That based on staff interviews and a review of facility Continuous Quality Improvement (CQI) meeting agendas, the facility failed to have a Quality Assessment and Assurance committee that identified, developed and implemented appropriate plans of action to correct identified quality deficiencies. This failure to respond to facility abuse and neglect issues resulted in actual harm to Resident #139, and residents experiencing fear and anguish due to the facility's failure to monitor aggressive behaviors. 29 Resident # 117 168. That the facility failed to identify a resident who was potentially at risk of injuring other residents, or putting into place interventions to prevent escalating behaviors and injury to others for Resident #117. 169. That the facility failed to assess and/or consult with the attending physician or the " psychiatric physician regarding the resident's behaviors which resulted in an injury to Resident #139. 170. That the facility neglected to investigate the incident of resident on resident behavior that resulted in Resident #139 being pushed to the ground by Resident #117 on 5/24/09 resulting in a broken hip. The facility did not investigate the incident, including calling the Medical Director nor the Psychiatrist to inform them of the incident and immediately putting into ) place plans to ensure that the harm, that occurred to Resident #139, did not happen again. 171. That an interview on 6/1/09 at 1 1:10 am with Resident #118, who resides in the room next to Resident #117 and Resident #4, who was the roommate of Resident #117, revealed that these residents lived in fear that the resident may come into their room and cause harm to them. 172. That on 6/4/09 at 1:20 PM during an interview with the Director of Nursing (DON) she stated that Quality Assessment (QA) issues are brought to the committee from the Quality Measure/Quality Indicator Report (QMQI). The facility did not have an identified action plan currently in place for any issue, including the incident that resulted in injury to Resident #139. Review of facility CQI meeting agendas for the last six months revealed that the committee was reviewing prior citations. However, no other issues were discussed. 30 173. That the DON went on to say during this interview that the facility did know of the potential resident on resident aggression and physical violence occurring in the facility. 174. That during interviews with staff members there was no knowledge of what QA was and/or what QA did as evidenced by an interview on 6/4/09 at 12:40 PM with a nurse who was asked about her knowledge of QA. She stated that she would take any issues to the Social Services Director (SSD). 175. That at 12:45 PM the Activity Director was asked about her knowledge of QA and responded that she would report to the SSD. 176. That at 1:00 PM another nurse was asked about her QA knowledge and responded that she could not speak to that and didn't know what that was. 177, That at 1:05 PM the Unit Manager was asked about her knowledge of QA and she stated that she would speak to the SSD about QA issues. 178. That at 1:10 PM a CNA was interviewed about her knowledge of QA and she "stated that she would report QA issues to the SSD. 179, That five residents were included as part of the Extended Survey, 6/3-5/09. Residents #117 and #34, and additional residents identified by the facility, were identified as potentially at risk to harm other residents. 180. The above findings reflect Respondent’s failure to identify concerns and develop plans of action to address care and service issues that impacted the health and safety of residents, thus the Respondent’s actions constituted a Class I deficiency, pursuant of § 400.23(8)(a), Florida Statutes (2008), 181. 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 31 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 $12,500.00 against Respondent, a nursing facility in the State of Florida, pursuant to § 400.23(8)(a), Florida Statutes (2008). COUNT V 182. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I, Il, I and IV of this complaint as if fully set forth herein. 183. Based upon Respondent’s cited State Class I deficiencies, 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)(b), Florida Statutes (2008), 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 (2008) commencing June 5, 2009 and ending July 4, 2009. 32 COUNT VI 184. The Agency re-alleges and incorporates paragraphs one (1) through five (5) and Count I, I, Ill and IV of this complaint as if fully set forth herein, 185. Respondent has been cited for four (4) State Class I deficiencies 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 (2008). 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 (2008). 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, IL, NI, IV, V and VI; and (B) Recommend an administrative fine against Respondent in the amount of $50,000; and (C) Assign a conditional licensure status commencing June 5, 2009; 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. 33 i UF Pe, “D. Carlton Enfinger ,“/ —— Fla. Bar.0793450 ‘ Agency for Health Care Admin. 2727 Mahan Drive; MS #3 Tallahassee, Florida 32308 850.922.5873 (office) 850.921.0158 (fax) CERTIFICATE OF SERVICE I CERTIFY that a copy hereof has been furnished to Terry K. Carpenter, Administrator, Glenwood Nursing Center, 40 Acme Street, Jacksonville, Florida 32211, by U.S. Certified Mail, Return Receipt No. 7004 2890 0000 5526 9906 and to John F. Gilroy,, III, P.A. , Registered Agent, 1695 Metropolitan Blvd., Suite 2, Tallahassee, Florida by email on rung. 2010. cc: Rob Dickson, FOM 34

Docket for Case No: 10-006442