STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, — _ Petitioner, vs. . CaseNos. 2011002213 (Fines) 2011002214 (Cond.) GINGER DRIVE HEALTH CARE ASSOCIATES, LLC, d/b/a HERITAGE HEALTH CARE CENTER, Respondent. / AD ISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (“the Agency”), by and through the undersigned counsel, and files this Administrative Complaint against the Respondent, Ginger Drive Health Care Associates, LLC, d/b/a Heritage Health Care Center (“the Respondent” , pursuant to sections 120,569 and 120.57 Florida Statutes, and ‘alleges as follows: ) NATURE OF THE ACTION This is an action to impose an administrative fine in the amount of $2,500.00 and assign conditional licensure status on the Respondent, a nursing home. PARTIES es The Agency is the licensing and regulatory authority that. oversees nursing homes and enforces the applicable federal regulations, state statutes and rules governing skilled nursing facilities pursuant to Chapters 408, Part JI, and 400, Part I, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. 2 The Respondent was issued a license (License Number 12210961) by the Agency Filed April 26, 2011 2:36 PM Division of Administrative Hearings } ' to operate a nursing home located at 3101 Ginger Drive, Tallahassee, Florida 32308, and was at’ all times material times required to comply with all applicable regulations, statutes and rules. COUNTI: 3.° Under Florida law, all licensees of nursing home facilities shall adopt and make public a statement of the rights and responsibilities of the residents of such facilities and shall treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following: .... (1) The right to receive adequate and appropriate health care and protective and support services, including social services; mental health services, if available; planned recreational activities; and therapeutic and rehabilitative services consistent with the resident care plan, with established and recognized practice standards within the community, and with rules as adopted by the Agency. § 400.022(1)(1), Fla. Stat. 4.. Under Florida law, in addition to the grounds listed in Part I 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. § 400.102(1), Fla. Stat. 5. On Pebruary 1, 2011, the Agency conducted a survey of the Respondent and its facility. 6. ‘Based upon observation, interview and record review, the Respondent failed to identify, assess, treat, and obtain physician orders for wound care for 3 of 4 sampled residents (Residents #1, #2 and #3). Resident # 1 7. Resident #1 was originally admitted to the facility in 2010. 8. On January 17, 2011, Resident #1 was sent to the hospital for difficulty with breathing. 9. On January 21, 2011, Resident #1 returned to the facility. 10. Resident #1 remained in the facility for 2 days, and was then sent back to the hospital on January 23, 2011. 11. On January 29, 2011, Resident #1 was re-admitted to the facility. 12. The facility treated each Resident admission as a separate occurrence and initiated anew medical record with each admission. Medical records from the previous admissions were obtained and reviewed. ' 13. On January 17, 2011, Resident #1 was residing in the facility. 14. A-record review for wound assessments was conducted. The “skin sweep” form was reviewed. A “skin sweep” form is used to document weekly skin assessments by the nursing staff. 15. The skin sweep forms from December 7, 2010, through January 17, 2011, were ‘reviewed. They showed weekly skin assessments to a wound on Resident #1’ coccyx. The skin sweep forms did not identify any other observed wounds. 16. The nurse's notes from December 1, 2010, through January 17, 2011, were reviewed. There was no indication of any skin wounds. 17. ) Resident #1 was sent from the facility to the hospital on January 17, 2011, for difficulty with breathing. 18. The hospital emergency room physician documented that Resident #1 had several unstageable heel sores and a stage 3 pressure ulcer to the tail bone area. 19. The hospital identified and photographed multiple skin wounds including unstageable wounds to the heels, an unstageable wound to the right second toe, an unstageable j } wound to the top of the left foot, an unstageable wound to the left calf below the knee, and a stage 3 pressure ulcer to. the coccyx (tail bone). Only the coceyx wound had been previously identified by the facility prior to hospitalization. . 20. Resident #1 returned to the facility on January 21, 2011. Upon return, the facility completed an admission assessment. The skin assessment identified wounds consistent with the _ wounds identified at the hospital. . 2. On January 23, 2011, Resident #1 was again sent from the facility to the hospital for difficulty with breathing. 22. . Resident #1 was re-admitted to the facility on January 29, 2011. The current medical record was reviewed. The nurse completed the admission-readmission data collection and initial plan of care at 3:15 p.m. “The nurse documented only 2 skin wounds: a An open area-bony prominence left lower extremity just below the knee, anterior outer area (however, on the body image the right extremity was checked) db. An open area-coccyx/center bony area. 23. On February 1, 2011, at approximately 12:35 p.m., an observation of current wounds was conducted with the wound care nurse for Resident #1. 24. The wound care nurse identified 7 wounds on the Resident's coccyx and legs, as follows: a, An open wound to the coccyx. The wound was surrounded by scar tissue and showed evidence of granulation. b. A small healing wound to the right shin. The wound appeared to be a small laceration measuring approximately 2 cm long, 3 mm wide and 2 mm deep. Cc. A wound to the right second toe. The wound measured approximately 0.5 cm in diameter, and was blackish in color. d. A wound with eschar (black area) to the right inner hee! measuring about 1.5 em. } } e. A deep tissue injury to the right outer heel. The area was about 2 om round, blackish in color, and peeling. f. A wound to the left outer heel, blackish in color, and measuring about 1,5 em round. g. A wound covered by a dressing to the left calf. The dressing was dated as last changed on January 26, 2011 - six days earlier. The dressing was removed to reveal a small open and draining wound about 1.5 cm in diameter with a black ring around the wound edges. 25. On February 1, 2011, at approximately 1:00 p.m., an interview was conducted with the wound care nurse after the wound observation. The nurse stated that she performs a full baseline skin assessment on all residents that are referred to her for wound care. These assessments are conducted within 72 hours after admission. "26. — Resident #1 was re-admitted to the facility from the hospital on January 29, 2011. 27. The wound care nurse looked at the Resident's current medical record. The wound care nurse stated that prior to this observation, only the wounds to the coccyx and right shin were identified. No other wounds had been documented. 28, There were no current physician orders for wound care. 29. The wound care nurse stated that no “skin grids” had been initiated. A skin prid is the form used to document the type, size and characteristics of wounds. . 30. The wound care nurse stated that she would now initiate the skin grid forms, review the treatment protocol, and obtain physician orders for wound care. 31. Arecord review to determine the date of onset, assessment and treatment for the observed wounds was conducted. 32. . The wound care nurse failed to identify or assess the other wounds as identified in the hospital admissions and the previous facility admission. 33. The treatment administration record was also reviewed. ; : 34. The nurse initiated treatment to the wound on the coccyx. 35. The treatment record had an order that read to cleanse coccyx with normal saline and apply hydrocolloid dressing and to change dressing every 3-4 days and as needed. 36. The nurse failed to obtain physician orders for this treatment. 37. A further current record review was conducted on February 1, 2011. There were no physician orders for wound care. 38. The nursing progress notes were reviewed from admission on January 29, 2011, through the present date of February 1, 2011, at approximately 12:30 p.m. 39. There were no other skin wounds identified. There was no further documentation of the identified wounds on the leg and coccyx. There were no measurements, the wounds were not identified as to type, and they were not staged. 40. Areview of the facility's protocol for wound care was conducted. 41. The protocol stated to select the treatment protocol based on the type/stage of wound, depth and drainage, then obtain a physician's order. 42. On February 1, 2011, at approximately 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON confirmed that a skin grid should have been initiated for all wounds. The admitting nurse was responsible for wound assessment to include type, size and characteristics. This should not be left for the wound care nurse to initiate, 43. The DON confirmed that physician orders should have been obtained. 44. The DON stated that the facility had identified concerns in the area of wound assessment and had recently in-serviced all nursing personnel on wound assessment. Resident #3 ‘45, On February 1, 2011, at approximately 1:50 p.m. a wound observation was ‘3 ! noe conducted with a floor nurse for Resident #3, 46. Resident #3 had a wound to the left foot. 47. The dressing on the Resident's foot was dated January 30, 2011, 2 days earlier. 48. The nurse removed the dressing and stated that the wound looked better. 49. A record review for the left foot wound on Resident #3 was conducted. - 50. On January 15, 2011, the physician had ordered daily dressing changes for the Resident for 2 weeks, 51. On January 19, 201 1, the physician ordered the Resident an antibiotic (Bactrim) for 10 days due to cellulitis (skin infection) of the left foot. 52. On January 28, 2011, the physician re-ordered the Resident the antibiotic as the wound had not completely healed. 53. The orders for daily dressing changes were not extended or re-ordered. 54. The dressing change orders had ended on J anuary 29, 2011. 55. During an interview with the floor nurse on February 1, 2011, at approximately 2:10 p.m, the nurse stated that the orders for the dressing change should have been renewed. 56. The nurse stated that she was going to obtain physician orders prior to re-dressing the wound. . Resident #2 57. A closed record review was conducted for Resident #2, Based upon the record review, Resident #2 had inaccurate and inconsistent skin and wound assessments. 58. The weekly skin assessments showed no new skin impairment from November 9, 2010, through January 11, 2011. 59. On January 17, 2011, a nurse documented new skin impairments to the left shin vet and left heel, The form stated to see progress note for details. . 60, Progress notes for Resident #2 were reviewed. 61. On January 17, 2011, a nurse wrote that she identified a 3 cm blackened area to the lefl knee with redness surrounding the blackened area. There was no drainage. . 62, The nurse also identified a 2 cm blackened area to the left heel. 63. The nurse notified the physician and the wound care nurse. 64: On January 18, 2011, a nurse documented that Resident #2 had wounds to the left heel and knee as noted the day before. . 65. “In addition, the nurse also identified a wound to the resident's left shin. 66. The skin grids for pressure and non-pressure related wounds were reviewed. Only one of the three identified wounds was documented on a skin grid. 67. The skin grid documented an unstageable wound to the left heel on January 15, 2011, two days prior to the initial nursing assessment. . 68. The wound measured 0.8 by 1.3 em and was black in color without drainage. 69. This form was not updated after the initial assessment. 70. Physician orders were obtained to clean and dress the left heel wound daily. There were no physician orders for the wounds to the left shin and left knee. 71. The care plan was updated on January 15, 2011, 72. The care plan identified an unstageable wound to the left heel and unstageable wounds to the left knee/shin. 73. There were no Skin Grids developed for the wounds to the left shin and knee, 74, “There were no further assessments in nursing notes to the wound on the left shin. 75. On January 23, 2011, Resident #2 was sent to the hospital for decreased mental status. 76. The emergency room physician identified four leg wounds and documented: ‘a) A 5-6 om circular ulcer with eschar formation (black scab like covering) Over the left knee, 2. A 3-4 cm ulcer with eschar on the left shin (several inches below the knee) b) A 3-4 cm ulcer with eschar on the left heel with mild surrounding redness c) A stage 1 decubitus pressure ulcer to the right heel. “77. On February 1, 2011, at Approximately 3:45 p.m., during an interview with the wound care aurse, the nurse stated that she examined the wounds to the knee, shin and heel. 78. She obtained a wound culture of the knee on January 18,2011. 79, The wound did not appear new to her. ~ 80. She stated that the floor nurses were taking care of the knee and shin wounds as they were scabbed. She was treating the heel wound. ; 81. On February 1, 201 1, at approximately 4:00 p.m., an interview was conducted: with the Director of Nursing (DON). The DON confirmed that no wounds had been documented by nursing prior to January 17, 2011. 82. The DON further stated that skin grids should have been initiated for ongoing and consistent assessment and physician orders should have been obtained, 83. The DON further stated that extensive in-services on wound assessment had oceurred on January 14, 2011, and the facility was monitoring this. 84. The Respondent’s actions and/or inactions constituted a violation of the above- referenced provision of law and amount to an isolated Class II deficiency pursuant to section 400.23(8)(b), Florida Statutes. WHEREFORE, the Petitioner, State of F lorida, Agency for Health Care Administration, intends to impose an administrative fine against the Respondent in the amount of $2,500.00. COUNT IT 85. The Agency re-alleges and incorporates by reference Count I. 86. Based upon the above cited state class II deficiency, the Respondent was not in substantial compliance with criteria established under Chapter 400, Part I, Florida Statutes, or the rules adopted by the Agency, subjecting the Respondent to assignment of a conditional licensure status under Section 400.23(7)(b), Florida Statutes. WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, intends to assign conditional licensure status to Respondent commencing February 1, 2011, and ending February 9, 2011. - CLAIM FOR RELIEF WHEREFORE, the State of Florida, Agency for Health Care Administration, respectfully seeks a final order that: | I. Makes factual and legal findings in favor of the Agency. 2. Imposes the relief set forth above. Respectfully submitted on this 24 day of _/ Vprac k , 2011. D. Carlton Enfinger, Es Assistant General Co Florida Bar No. 7934 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5407 Telephone: 850-412-3640 Facsimilie: 850-921-0158 10 sage? ee NOTICE The Respondent has the right to request:a hearing to be conducted in accordance with Sections 320.569 and 120.57, Florida Statutes, and to be represented by counsel or other qualified representative. Specific options for the administrative action are set out Within the attached Election of Rights form. The Respondent is further notified if the Election of Rights form is not received by the Agency for Health Care Administration within twenty-one (21) days of the receipt of this Administrative Complaint, a final order will be entered. The Election of Rights form shall be made to the Agency for Health Care Administration and delivered to: Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Mail Stop 3, Tallahassee, FL 32308; Telephone (850) 412-3630. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been served by US. Certified Mail, Return Receipt No. 7009 0960 0000 3708 3383 to Anthony J. Pileggi, Administrator, Heritage Health Care Center, 3101 Ginger Drive, Tallahassee, Florida 32308, and by U.S. Mail to Registered Agent Corporation Service Company, 1201 Hays Street, Tallahassee, Florida 32301, and via email to Anna Gay Small, Esquire, Broad and Cassel, 215 South Monroe Street, Suite 400, Tallahassee, Florida 32301 on this) d day of Vow C is »2011: D. Carlton Enfinger, Esqfife Assistant General Couns@l Florida Bar No. 793450 Office of the General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308-5407 Telephone: 850-412-3640 Facsimilie: 850-921-0158 Copy: Barbara Alford, Field Office Manager ih

Docket for Case No: 11-002097