tone sh, STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, vs. . Case No. 2011002121 BETHESDA SENIOR CARE, INC. d/b/a BETHESDA ON TURKEY CREEK, Respondent. . / COMES NOW the STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION (hereinafter “Petitioner” or “Agency”), by and through the undersigned counsel, and files this Administrative Complaint against BETHESDA SENIOR CARE, INC. d/b/a BETHESDA ON TURKEY CREEK (hereinafter “Respondent”), pursuant to § 120.569 and § 120.57, Fla. Stat. (2010), and alleges: i NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of One Thousand and No/100 ($1,000.00) Dollars and a survey fee in the amount of Five Hundred and No/100 ($500.00) Dollars based upon one (1) cited State Class II deficiency violation pursuant to § 429,19(2)(b) and § 429,19(7), Fla. Stat. (2010) for a total assessment of One Thousand Five Hundred and No/100 ($1,500.00) Dollars. JURISDICTION AND VENUE 1. The Agency has jurisdiction pursuant to § 20.42, § 120.60 and Chapters 408, Part II, and 429, Part I, Fla. Stat. (2010). Filed April 21, 2011 11:30 AM Division of Administrative Hearings 2. Venue lies pursuant to Florida Administrative Code R. 28-106.207. PARTIES 3. The Agency is the regulatory authority responsible for licensure of assisted living facilities and enforcement of all applicable regulations, state statutes and rules governing assisted living facilities pursuant to the Chapters 408, Part II, and 429, Part I, Florida Statutes, and Chapter 58A-5, Florida Administrative Code. 4, Respondent operates a 97-bed assisted living facility (hereafter “ALF”) located at 2800 Fordham Road, N.E., Palm Bay, FL 32905, and is licensed as an ALF, license number 4788. 5. Respondent was at all times material hereto a licensed. facility under the licensing authority of the Agency, and was required to comply with all applicable rules and statutes. COUNT I (Tag: A700) ) 6. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 7. That pursuant to Florida law, “[a]n assisted living facility shall provide care and services appropriate to the needs of residents accepted for admission to the facility.” Fla. Admin. Code R. 58A-5.0182. 8. ‘That on 01/24/11, the Agency conducted a Complaint Survey (CCR No. 2010012878) of the Respondent’s facility. 9. That based upon interview and record review: a. Respondent failed or refused to provide care and services appropriate to the needs of four (4) of fifteen (15) sampled residents, specifically Resident No. 3, Resident No. 4, Resident No. 8 and Resident No. 15 (hereafter “R3”, “R4”, “R8”, and “R15”) and a Random Sample Resident, hereafter “RS1”; ee ae Page 2 of 13 b. Respondent did not have a system in place to ensure that all narcotics. and comfort packs were accounted for and available at all times for residents; and c, Respondent did not have a working system to ensure Respondents staff did not take medications for personal use or gain. i 10. That a telephone call to the Hospice Pharmacia on 01/21/11 at approximately 11:00 AM : revealed that, per hospice customer service staff: a. The comfort pack for R3, with Prescription No. 802217718 that contained | morphine sulfate 20 mg./ml. and was dispensed on 04/14/10 and’ delivered to Respondent’s facility on 04/16/10, was not returned to the pharmacy. ! ' _b, The comfort pack for R4, with Prescription No. 802221209 that contained morphine sulfate 20 mg,/ml. and was dispensed on 4/16/10 and delivered to Respondent's facility on 04/19/10, was not returned to the pharmacy. li. That regarding R3: a. R3 had an AHCA Health Assessment Form 1823, hereafter “1823”, dated 08/19/10 listing a diagnosis of dementia. b. R3 required supervision with self-administration of medications. c¢. R3 was discharged from hospice services on 12/04/10 because of “extended _ prognosis”, d.’ Continued record review revealed no notations regarding when the comfort pack that contained morphine sulfate 20 mg/ml was received by Respondent's facility or the disposition of the hospice comfort pack. ' Comfort packs included Atropine, Tylenol suppositories, Phenergan suppositories, Roxanol and Ativan. Page 3 of 13 12. That regarding R8: a. R8& had an 1823 dated 09/09/10 indicating diagnosis of CHF, CAD and TN. b, R& was under the care of hospice. c. Facility note dated 12/14/10 indicated R8 “went out to hospital today. On Vitas hospice at the time, but they were taking too long to respond”, d. Another note dated 12/14/10 indicated that the “resident was having difficulty breathing - CNA put [gender noted] to bed and contacted the hospice nurse that was on the property. 1 asked the nurse to give resident med’s from the comfort pack. He told me that resident didn’t have a comfort pack. I told him [gender : noted] had two one regular and 1 cardiac. I asked him to come to the resident’s room. I told him I was sending [gender noted] to the ER because [gender noted] needed relief. Hospice said they were discussing what [gender noted] needed. I called 911 and send (sic) [gender noted] to the hospital.” “e. That a note dated 12/24/10 indicated that R8 retuned to the facility, “they said [gender noted] was non-responsive, however [gender noted] was smiling and responsive to us - happy to be back”. f. That a note dated 12/25/10 indicated R8 was transferred to hospice unit because the facility was unable to administer Roxanol and the hospice had no “eo (comfort care) coverage for holiday”, g. The hospital discharge summary dated 12/14/10 indicated diagnoses of sepsis, 2 A comfort pack contained narcotics and palliative medications for residents on hospice crisis ‘care/end of life. Page 4 of 13 13. That Respondent’s Assistant Administrator claimed on said date 01/24/11 at approximately 3:30 PM that a hospice nurse took it upon herself to destroy comfort packs because some of the medications had expired. 14. That regarding R15: a. R15 had a health assessment report dated 08/31/10 indicating diagnoses of stomach ulcer, small bowel obstruction, COPD, HTN, COPD and A fib; supervision was needed with self-administration of medications. A prescription dated 08/31/10 indicated Hydrocodone/Apap10/650 mg one (1) _ every six (6) hours as needed. On 09/20/10, an order indicated Ultram 50 mg one (1) every six (6) hours. Order dated 11/17/10 indicated Hydrocodone/Apap 10/650 mg one (1) three (3) times daily as needed for pain, one hundred (100) were ordered. The November 2010 MOR listed Hydrocodone /Apap 10/650 one (1) tablet every ° six (6) hours as needed for pain and was taken three (3) times on 11/1, two (2) times on 11/2, 11/3, and one (1) time on 11/4 and 11/5. i. On 11/6, staff initials were circled; ii. Blank from 11/7 to 11/9, 11/13 and 11/15, and staff circled with a line across and indicated “error” from 11/10, 11/11, 11/12, 11/14; iii. 11/16 had staff initials three (3) times, indicating the resident took the medication three (3) times that day. iv. A hand written note indicated “New order 11/17/10”. y. The back page of the MOR indicated the resident requested the medication three (3) times on 11/1, twice on 11/21 and once 11/3 and 11/4, Page 5 of 13 vi. On 11/6, 11/7 and 11/12 it was indicated that the medication was not on hand and was also crossed off. On 11/15 notations indicated that the medication was taken at 6:00 PM, 11/16 at 5:45 AM, 2:40 PM and 8:45 PM. vii. The resident took Ultram 50 mg on 11/15/10. viii, Respondent had no documentation available to explain what transpired to cause the resident to be without pain medication, or the discrepancy on the MOR. 15. That Respondent’s Administrator stated on said date 01/24/11 at approximately 2:00 PM that: a. Staff No. 1 had been terminated because a random drug test was positive for opiate- Morphine, propoxyphene (a narcotic no longer legal in the United States) and opiates (morphine/codeine), b. Staff No. 1 told Respondent's Administrator she would bring her prescription records to show she was on prescription medications only, but failed to provide them. c. StaffNo, 1 was suspected of taking R15’s medications. 16. That a statement of the internal investigation conducted and provided by Respondent’s Administrator indicated the following: a. On 11/5/10, Hydrocodone (an opiate narcotic) was reported missing. db. Respondent’s Administrator, who was out of town, was contacted. c. Respondent’s Administrator called and suspended Staff No. 1. Page 6 of 13 d. On 11/15/10, after returning from vacation, Respondent’s Administrator decided to have all Respondent’s med techs? take a random drug test. j e. The staff told her that Staff No. 1, who worked 11:00 PM to 7:00 AM, refused to ‘count medications at the end of their shift. i. Staff No. 1 made a “lot of stammering excuses none which were viable”, | ii. On 11/29/ 10, Staff No. 1 was suspended until she brought in the pharmacy | ; . prescription history. i iii. Her drug test results, dated 11/29/10, indicated that the urine specimen 1 ; collected on 11/15/10 was positive for propoxyphene, opiates and morphine. iv. Duting her suspension another, staff said that Staff No. 1 went to visit her and said she had some pills to sell. y. She further explained her brother was a doctor and she needed money to take to her father. After hearing this, Respondent’s Administrator terminated the staff who said that the “pills were not from Bethesda and it . was the first time she ever did anything like this she made a mistake and it was a bad choice”, 17. That review of the patient prescription record, dated from 03/29/10 to 10/24/10 and i ptovided by the facility, indicated R15 received thirteen (13) prescriptions for Hydrocodone - Apap 5-500, and fifteen (15) prescriptions of Propoxyphene HCL 65 mg, but there was no record to indicate that s/he was prescribed Morphine. : 3 “Med Tech” is a term used for a caregiver who attended a 4-hour medications class. Page 7 of 13 18. That record review on 01/24/11 at approximately 12:00 PM revealed R4 had an 1823 dated 11/10/10 indicating diagnoses of end stage dementia and hypertension. a. R4 needed assistance with ambulation, bathing, dressing, grooming eating, toileting and transferring and required assistance with self-administration of medications. b. R4 resided in the Memory Care Unit (hereafter “MCU”), was on Hospice, and was unable to be interviewed due to his/her cognitive status. 19, . That review of physician’s orders dated 11/07/10 revealed Comfort Pack, may use Comfort Pack at nurses’ station for comfort care. . 20, That confidential information received revealed a Fed-Ex Tracking number: 415336072859 containing Prescription (RX) number (#) 802221209 CP Morphine 20 milligrams (mg)milliliter (ml) CONC Quantity: 15 cubic centimeter (CC) was delivered on 04/19/10 at 12:40 PM to Respondent’s facility. . a. After delivery, the comfort pack and morphine was placed in the locked refkigerator, b. On 11/16/10 the Vitas Nurse went to check morphine and the comfort pack was gone. 21. That Respondent’s facility did not provide any documentation that the comfort pack and Morphine were: a. Received by Respondent’s facility; b. Used by the resident; or c. Disposed of. Page 8 of 13 22. That furthermore, Respondent did not have a procedure to account for Comfort Packs. 23. Medication review revealed Morphine Sulfate RX#1703810-04816 (with a fill date of 11/7/10) was on hand. 24, That during an interview with Respondent’s Administrator on 01/24/11 at approximately 4:55 PM, Respondent's Administrator stated she did not know where the Comfort Pack went. 25. That during a phone interview on 01/24/11 at approximately 12:20 PM with the Hospice Team Manager, the Hospice Team Manager stated/claimed the Comfort Packs were sent back to hospice or destroyed. a The hospice facility nurse, who was working at that time, was no longer employed with the hospice. The hospice nurse who. contacted the mail order pharmacy stated there were comfort packs ordered, but when they went to check on the comfort packs - they were not in the facility. The mail order pharmacy would not send comfort packs to the facility anymore. - He continued that hospice orders the narcotics on an individual basis now. Two (2) weeks ago they had a nutse here at hospice and they destroyed the packs. There were none missing. The nurse was to fill out a form when the narcotics ‘were destroyed. A nurse destroyed about twelve (12) to thirteen (13) comfort packs about one and a half (1 %) months ago. “I shredded the form with the resident names on it that included the narcotics that were destroyed”. Hospice did not have documentation of the narcotics that were destroyed. He recalled that the Comfort Packs for R3 and R4 were “missing” since November, before the nurse destroyed twelve (12) ot thirteen (13) packs. Page 9 of 13 26. That Respondent's Administrator admitted on 01/24/11 at approximately 4:00 PM that Respondent’s facility, prior to November, did not have a system in place to track the narcotics, Comfort Packs received; the medications were stored in the refrigerator or in the medication cart. 27. That medication review in the MCU on 01/24/11 at approximately 10:30 AM revealed RSI received assistance with self-administration of medication and was prescribed Lorazepam (agitation) 0.5 mg every eight (8) hours. a, Review of the narcotic sheet for 12/14/10 through 01/24/11 revealed Respondent’s facility received thirty (30) ml of Lorazepam on 12/14/10 and the amount remaining on 01/24/11 was 24.50 ml. . -b, The bottle of Lorazepam had eighteen (18) ml remaining on 01/24/11. c. Review of the Narcotics Sign-Out Sheet, the December 2010 and January 2011 Medication Observation Records (hereafter “MORs”) and the back of both of the MORs revealed there was no documentation to review to {indicate the resident received a total of forty-eight (48) doses of Lorazepam.’ d, The back of the MORs stated multiple resident refusals or resident asleep. 28. That Respondent had no documentation to indicate when or if the Lorazepam was wasted - ot any indication for the discrepancy between the narcotic count and the actual amount on hand. 29, That the MORs were not legible and not able to be determined at all times when the initials were circled as not given or the initials were charted as given. 30. That Respondent’s facility did not have a system in place to document wasted narcotic medications in order to facilitate keeping an accurate narcotic count. doses per ml = forty-eight (48) doses. Page 10 of 13 fale 31. That during an interview with Respondent’s Administrator and Assistant Administrator on 01/24/11 at approximately 5:00 PM, they stated they were unaware of the reason there was a discrepancy in the narcotic count. 32. That the Agency determined this deficient practice was related to the operation and maintenance of a provider or to the care of clients which the Agency determines directly threaten the physical or emotional health, safety, or security of the clients, other than class I violations and cited Respondent for a State Class II deficiency violation. . 33. That the same constitutes grounds for a State Class II deficiency violation as defined by law. 34.. That in the case at bar, the above reflect, inter alia, that Respondent provide care and services appropriate to the needs of residents accepted for admission to the facility due to a systematic failure to have a system in place to not only ensure all narcotics and Comfort Packs were accounted for and available at all times to residents, but also ensure Respondent’s staff did not take medications for personal use or gain, which is contrary to law. 35. That the Agency provided Respondent with a mandatory correction date of 02/22/11. WHEREFORE, the Agency intends to impose an administrative fine in the amount of One Thousand and No/100 ($1,000.00) Dollars, against Respondent, an ALF in the State of Florida, pursuant to § 429.19(2)(b), Fla. Stat. (2010). COUNT JL (Survey Fee) 36. The Agency re-alleges and incorporates paragraphs one (1) through five (5) as if fully set forth herein. 37. That pursuant to § 429.19(7), Fla, Stat. (2010), “{iJn addition to any administrative fines imposed, the agency may assess a survey fee, equal to the lesser of one half of the facility's biennial license and bed fee or $ 500, to cover the cost of conducting initial complaint Page 11 of 13 investigations that result in the finding of a violation that was the subject of the complaint or monitoring visits conducted under s. 429.28(3)(c) to verify the correction of the violations.” 38. That pursuant to § 429,19(7), Fla. Stat, (2010), such a finding subjects Respondent to a survey fee equal to the lesser of one half of the Respondent’s biennial license and bed fee or five hundred dollars ($500.00). 39, That Respondent is therefore subject to a survey fee of Five Hundred and No/100 ($500.00) Dollars, pursuant to § 429,19(7), Fla, Stat. (2010). WHEREFORE, the Agency intends to impose an additional survey fee of Five Hundred and. No/100 ($500.00) Dollars against Respondent, an ALF in the State of Florida, pursuant to § 429,19(7), Fla. Stat. (2010). “ Respectfully submitted this 2-! * day of March, 2011. . STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION The Sebring Building . 525 Mirror Lake Dr. N., Suite 330 St. Petersburg, Florida 33701 Telephone: (727) 552-1942 Facsimile: (727) 552-1440 E-mail: Thomas. 'y@ahca.myflorida.com By: Thomnas F. Asbury, Esq. Fla Bar No. 567523 Respondent is notified that it has a right to request an administrative hearing pursuant to Section 120.569, Florida Statutes. Respondent has the right to retain, and be represented by an attorney in this matter. Specific options for administrative action are set out in the attached Election of Rights. Page 12 of 13 All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Bldg #3, MS #3, Tallahassee, FL 32308; Telephone (850) 412-3630. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO REQUEST A HEARING WITHIN 21 DAYS OF RECEIPT OF THIS COMPLAINT WILL RESULT IN AN ADMISSION OF THE FACTS ALLEGED IN THE COMPLAINT AND THE ENTRY OF A FINAL ORDER BY THE AGENCY. CERTIFICATE OF SERVICE 1 HEREBY CERTIFY that a irue and correct copy of the foregoing has been furnished by US. Certified Mail, Return Receipt No. 7009 0960 0000 3708 3215 on the 2{* day of March, 2011 to Respondent, ATTN: Neil J, Buchalter, Registered Agent, 2395 North Courtney Pkwy, Suite 201, Merritt Island, FL 32953 and by U.S. Mail to Respondent, ATIN: Linnie Digiacomo, Administrator, 2800 Fordham Road, N.E., Palm Bay, FL 32905. Thomas F, Asbury, Esq. Senior Attorney Copies furnished to: Lorraine Henry, AHCA, Health Facility Evaluator Supervisor (Interoffice) Page 13 of 13 USPS - Track & Confirm Ea fess. AHCA vs. Bethesda on Turkey Creek ‘ : Home | Help | Sign In Case No. 2011002121 Track & Confirm Search Results Label/Receipt Number: 7009 0960 0000 3708 3215 ‘ee Service(s): Certified Mail™ Track & Confirm Status: Delivered Enter Label/Receipt Number. Your item was delivered at 12:04 pm on March 23, 2011 in MERRITT ISLAND, FL 32953. Detailed Results: » Delivered, March 23, 2011, 12:04 pm, MERRITT ISLAND, FL 32953 » Arrival at Unit, March 23, 2011, 6:07 am, MERRITT ISLAND, FL 32953 Notification Options Track & Confirm by email Get current event information or updates for your item sent to you or others by email. FOIA http://trkcnfrm1 .sml.usps.com/PTSInternetWeb/InterLabelInquiry.do [04/20/2011 10:48:00 AM]

Docket for Case No: 11-002022