STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, Petitioner, AHCA No.: 2011003160 Return Receipt Requested: Vv. 7009 0080 0000 0586 1213 ANA HOME CARE, INC. d/b/a ANA HOME CARE, Respondent. ADMINISTRATIVE COMPLAINT COMES NOW State of Florida, Agency for Health Care Administration (“AHCA”), by and through the undersigned counsel, and files this administrative complaint against Ana Home Care, Inc. d/b/a Ana Home Care (hereinafter “Ana Home Care”), pursuant to Chapter 429, Part I, and Section 120.60, Florida Statutes (2010), and alleges: NATURE OF THE ACTION 1. This is an .action to revoke the assisted, living facility license [License No.: 11559] of Respondent, pursuant to Section 408.815(c), Florida Statutes, and Section 429.14(1) (e), Florida Statutes, and to impose an administrative fine of $20,000.00 pursuant to Sections 429.14 and 429.19, Florida Filed May 12, 2011 1:37 PM Division of Administrative Hearings Statutes (2010), for the protection of public health, safety and welfare. JURISDICTION AND VENUE 2. This Court has jurisdiction pursuant to Sections 120.569 and 120.57, Florida Statutes (2010), and Chapter 28-106, Florida Administrative Code (2010). 3. Venue lies pursuant to Section 120.57, Florida Statutes (2010), and Rule 28-106.207, Florida Administrative Code (2010). PARTIES 4, AHCA is the regulatory authority responsible for licensure and enforcement of all applicable statutes and rules governing assisted living facilities pursuant to Chapter 429, Part I, Florida Statutes (2010), and Chapter 58A-5 Florida Administrative Code (2010). 5. Ana Home Care operates a 6-bed assisted living facility located at 20555 S. W. 187 Avenue, Miami, Florida 33187. Ana Home Care is licensed as an assisted living facility under license number 11559. Ana Home Care was at all times material hereto a licensed facility under the licensing authority of AHCA and was required to comply with all applicable rules and statutes. COUNT I _ ANA HOME CARE FAILED TO PROVIDE SERVICES TO RESIDENT WHO WAS ADMITTED WITH A STAGE II PRESSURE ULCER. RULE 58A-5.0181(1) (j)1. & 2., FLORIDA ADMINISTRATIVE CODE (ADMISSIONS CRITERIA STANDARDS) CLASS I VIOLATION 6. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 7. Ana Home Care was cited with four (4) Class I deficiencies as a result of a licensure survey that was conducted on March 21, 2011 and March 22, 2011. 8. A licensure survey was conducted on March 21, 2011 and March 22, 2011 Based on observations, record review, and interview, it was determined that the facility failed to provide services to 1 out of 7 (Resident #1) sampled residents who was admitted with a stage II pressure ulcer. The findings include the following. 9. Record review found that resident #1 was admitted to the facility with a stage II pressure ulcer on 1/16/2011. Based upon record review and interview with the facility contracted nurse on 3/22/11 at approximately 11 AM, there was no documentation of caring for the resident's stage II pressure ulcer prior to hospitalization on 2/4/11 (a period of over two weeks without documented wound care). The facility did not provide any documentation regarding wound care orders and services that were provided to resident #1 from the admission date to the facility and the admission date to the home health services between 1/16/2011 to 2/18/2011. 10. On 02/19/2011 resident #1 was admitted to a home health agency with diagnoses: Osteomyelitis (an infection of the bone) and Decubitus Stage 4 pressure ulcer. The home health Plan of Care dated 02/19/2011 revealed pressure ulcer stage 4 on sacrum that measures 6.5cmx 5.0cm x 1.0cm, 3cm undermining from 10 to 6 0 ' clock. 11. Observation of resident #1 on 03/22/2011 at 10:15 AM by a nurse surveyor revealed dark sacral bed with full thickness tissue loss and more than moderate drainage on the dressing that was removed for observation. Interview with the facility contracted registered nurse (RN; staff #5) on 03/22/2011 at 11:50 a.m. revealed resident #1 did-return to the facility from the hospitalization with a wound that had worsened. She stated the resident required vacuum and antibiotic therapy at one point for the wound. 12. Based upon record review, the facility had contracted with a registered’ nurse (RN) to provide limited nursing services. Although this contract was in effect since 9/1/10 and this resident had significant clinical conditions requiring skilled nursing services (including a stage IV pressure ulcer with osteomylitis), there was no evidence the registered nurse was providing services to any facility resident under the LNS contract. Documentation of consistent, ongoing care of the wound was not present. 13. The facility’s failure to provide care and services to Resident #1 who was admitted with a stage II pressure ulcer placed the Resident at imminent danger or threat of serious physical harm. 14. Based on the foregoing facts, Ana Home Care violated Rule 58A-5.0181(1)(4) 1. & 2., Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $5,000.00, and which gives rise to the revocation of the assisted living facility license [License number: 11559]. COUNT II ANA HOME CARE FAILED TO DISCHARGE RESIDENT WHOSE STAGE II PRESSURE SORE FAILED TO IMPROVE WITHIN 30 DAYS, AND CONTINUED RESIDENCE FOR A RESIDENT WITH A STAGE IV PRESSURE ULCER. RULE 58A-5.0181(5), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0181(4) (b)3., FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0181(1) (3)3., FLORIDA ADMINISTRATIVE CODE RULE 58A-5.031(1) (j), FLORIDA ADMINISTRATIVE CODE (ADMISSIONS CRITERIA STANDARDS) CLASS I VIOLATION 14. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 15. A licensure survey was conducted on March 21, 2011 and March 22, 2011 Based on observations, record review, and interview, it was determined that the facility failed to discharge 1 out of 7 (Resident #1) sampled residents whose stage II pressure sore failed to improve within 30 days, and continued residence for a resident who has a stage IV pressure ulcer for 1 of 7 (Resident #1) sampled residents. The findings include the following. 16. Record review found that resident #1 was admitted to the facility with a stage II pressure ulcer on 1/16/2011. Based upon record review and interview with the facility contracted nurse on 3/22/11 at approximately 11 AM, there was no documentation of caring for the resident's stage II pressure ulcer prior to hospitalization on 2/4/11 (a period of over two weeks without documented wound care). The facility did not provide any documentation regarding wound care orders and services that were provided to resident #1 from the admission date to the facility and the admission date to the home health services between 1/16/2011 to 2/18/2011. 17. On 02/19/2011, resident #1 was admitted to a home health agency with diagnoses: Osteomyelitis (an infection of the bone) .and Decubitus Stage 4 pressure ulcer. The home health Plan of Care dated 02/19/2011 revealed pressure ulcer stage 4 on sacrum that measures 6.5cmx 5.0cm x 1.0cm, 3cm undermining from 10 to 6 0 ' clock. The Hospice Registered Nurse assessment visit form for resident #1 dated 03/15/2011 revealed wound measurement 7 centimeters (cm) x 8.2cm x 3.6cm, an increase in size since the previous measurement, indicating wound worsening. The resident remained in the facility with a stage IV pressure ulcer from 2/19/11 until admission to hospice on 2/28/11. 18. Observation of resident #1 on 03/22/2011 at 10:15 AM by a nurse surveyor revealed dark sacral bed with full thickness tissue loss and more than moderate drainage on the dressing that was removed for observation. Interview with the facility contracted registered nurse (RN; staff #5) on 03/22/2011 at 11:50 a.m. revealed resident #1 did return to the facility from the hospitalization with a wound that had worsened. She stated the resident required vacuum and antibiotic therapy at one point for the wound. 19. Rule 58A-5.0181(1)(5)3., Florida Administrative Code, provides that if a resident admitted with a stage II pressure sore fails to improve within 30 days, “the Resident shall be discharged from the facility.” (Emphasis added). 20. Rule 58A-5.0181(1) (43), Florida Administrative Code, provides that a person with a stage III or IV pressure sore is not appropriate for placement or for continued residency in an assisted living facility. 21. Rule 58A-5.031(1) (3), Florida Administrative Code, provides that a facility with LNS license cannot care for a resident that has a stage III or IV pressure sore. 22. Based on the foregoing facts, Ana Home Care violated Rule 58A-5.0181(4) (b)3., Florida Administrative Code, Rule 58A- 5¥0181(1) (j)3., Florida Administrative Code, Rule 58A~-5.0181(5), Florida Administrative Code, and Rule 58A-5.031(1)(4j), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $5,000.00, and which gives rise to the revocation of the assisted living facility license {License number: 11559]. COUNT III ANA HOME CARE FAILED TO ASSIGN DUTIES TO ITS STAFF CONSISTENT WITH HIS/HER LEVEL OF EDUCATION, TRAINING, PREPARATION, AND EXPERIENCE AND FAILED TO PROVIDE CARE AND SERVICES AS APPROPRIATE TO THE NEEDS OF THE FACILITY RESIDENTS. RULE 58A-5.019(2) (b), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0182, FLORIDA ADMINISTRATIVE CODE RULE 58A-5.0181(1) (k), FLORIDA ADMINISTRATIVE CODE RULE 58A~5.0181(4) (c), FLORIDA ADMINISTRATIVE CODE RULE 58A-5.031(1) (m), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS I VIOLATION 23. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 24. A licensure survey was conducted on March 21, 2011 and March 22, 2011 Based on observations, record review, and interview, it was determined that the facility failed to provide care and services as appropriate to the needs of facility residents in that they failed to assign duties to its staff - consistent with his/her level of education, training, preparation, and experience. This resulted in a failure to provide needed skilled services to two of seven facility residents (#1 and #4). The facility failed to utilize a nurse to administer stage 4 sacral wound care treatment, Central Venous Pressure site Care (CVP),° Foley Catheter Care, Percutaneous Endoscopic Gastrostomy (peg) tube feedings and medications for 2 of 7 (Resident #1 and Resident #4) sampled residents. The facility allowed unlicensed, unqualified staff to provide PEG tube feedings and PEG tube medication administration to resident #4.. In addition, the facility did not have documentation to demonstrate ongoing, consistent care of the stage IV pressure ulcer of resident #1, dressing changes for resident #1 and Foley catheter care for resident #1.. Lack of care for these residents resulted in a significant threat to their well-being. The findings include the following. 25. Based upon record review, the facility had contracted with a registered nurse (RN) to provide limited nursing services. Although this contract was in effect since 9/1/10 and facility residents #1 and #4 had significant clinical conditions requiring skilled nursing services, there was no evidence the registered nurse was providing services to any facility resident’ under an LNS contract. Facility record review also indicated there were no residents on an LNS log. This RN verified in an interview at approximately 11 AM on 3/21/11 that LNS services were not being provided to facility residents and LNS required documentation had not been completed and was not available for any facility resident. 26.- Record review revealed resident #1 was admitted to the assisted living facility (ALF) on 01/16/2011 based on the admission log with Dementia and Stage 2 Pressure Ulcer (AHCA form 1823) dated 1/16/2011. Based upon record review and interview with the facility contracted nurse on 3/22/11 at approximately 11 AM, there was no documentation of caring for the resident's stage II pressure ulcer prior to hospitalization on 2/4/11 (a period of over two weeks without documented wound care). 27. On 02/04/2011, resident #1 was transferred to hospital with flu-like symptoms and returned to ALF on 02/07/2011. On 02/09/2011 resident #1 was transferred to hospital with diagnosis of diarrhea and returned to assisted living facility on 02/18/2011. The facility did not provide any documentation regarding wound care orders and services that were provided to resident #1 between 1/16/2011 to 2/18/2011. 10 28. on 02/19/2011, resident #1 was admitted to a home health agency with diagnoses: Osteomyelitis (an infection of the bone), Decubitus Stage 4. pressure ulcer, Atrophy Gastritis without Hemorrhage, and Alzheimer's disease. On 2/28/11 (over a week after the resident returned to the facility with a stage IV - pressure ulcer), resident #1 was finally admitted to hospice care with diagnoses: End stage Cardiovascular Artery Disease, Dementia, Alzheimer's Disease and Sacral Decubitus stage 4.: The home health Plan of Care dated 02/19/2011 revealed pressure ulcer stage 4 on sacrum that measures 6.5cmx 5.0cm x 1.0cm, 3cm undermining from 10 to 6 0 ' clock. 29, Observation on 03/22/2011 at 7:10 a.m. revealed a cachetic female resident who looks pale and weak. The resident's legs were elevated while sleeping on a special mattress with evidence of breathing difficulty (dyspnea). The left leg was more swollen than the right Leg. An indwelling Foley catheter bag without urine drainage and brown sediments in the tubing and Foley bag was observed. 30. Observation of resident #1 on 03/22/2011 at 10:15 AM by a nurse surveyor revealed dark sacral bed with full thickness tissue loss and more than moderate drainage on the dressing that was removed for. observation. Observation on 03/22/2011 at 10:15 a.m. revealed central venous pressure (CVP) dressing with the date 03/15/2011. Record review found that the facility did not 11 have orders and instructions for CVP site dressing. Based upon record review, it could not be determined how the CVP was being care for. Based upon interview with the facility contracted nurse on 3/22/11 at approximately 11 AM, skilled care was to provide changing to the CVP dressing once every three days, although the dressing was dated as last being changed on 3/15/11 (one: week prior). 31. Observation on 03/22/2011 at 10:15 a.m. revealed resident was lying on the Foley catheter tubing. ALF staff was informed and resident was repositioned. Interview with the ALF aide on 03/22/2011 at 8:02 a.m. revealed the Foley bag had been emptied by the certified nursing assistant from hospice care that morning at 6:30 a.m. Based upon record review, there was no order within the facility indicating when or by whom the catheter tubing should be changed (although the standard of practice is generally at least monthly). There was no indication anywhere in the record for resident #1 when the tubing was last changed, for this catheter that had been in place for an undetermined amount of time. (There was no order found for initial insertion of the Foley catheter.) 32. In addition, the facility did not follow orders for provision of oxygen to resident #1. There was a physician order dated 02/28/2011 for oxygen at 2 liters (L)/minute via nasal canula. Multiple observations on 03/22/2011 of this resident 12 revealed no oxygen was provided, as ordered, to this debilitated resident. Times of these observations include: 7:10 a.m., 8:36 a.m., 10:15 a.m. 12:22 p.m., and to 1:41 p.m. The resident was observed at these times to have irregular breathing. 33. .The Hospice Registered Nurse assessment visit form for resident #1 dated 03/15/2011 revealed wound measurement 7 centimeters (cm) x 8.2cm x 3.6cm, an increase in size since the previous measurement, indicating wound worsening. The Infectious Disease Treatment (IDT) care plan dated 2/28/2011 revealed resident #1 lost 22 pounds in the last month. 34. Interview with the facility contracted registered nurse (RN; staff #5) on 03/22/2011 at 11:50 a.m. revealed resident #1 did return to the facility from the hospitalization with. a wound that had worsened. She stated the resident required vacuum and antibiotic therapy at one point for the wound. 35. Interview with the registered nurse from hospice on 03/22/2010 at 12:28 p.m. revealed he was in a meeting all day and he would visit the resident later in the day. The RN would not state when ‘asked what the physician order was for the frequency of the cvP site dressing change. The surveyor at this time made a second request for ‘the RN assessment notes and current physician orders since the resident had _ several significant changes at the ALF. Documents were not received prior to leaving the facility at 1:47 p.m. on 3/22/11. 13 36. Record review of resident #4 medical record revealed resident was admitted to the assisted living facility on 11/27/09 with diagnoses of dementia and legally blind. The agency for healthcare form 1823 revealed resident #4 required total assistance on admission for all activities of daily living which include ambulation, bathing, dressing, eating, grooming, toilet, and transfer, preparing meals, and daily oversight of his well-being. Diet: pureed, nectar thick. 37. Review of medical records revealed a physician order dated 01/25/2010 to refer resident to hospice services: status post cerebrovascular accident, status post myocardial infarction, senile dementia, Percutaneous Endoscopy Gastrostomy tube ' (PEG) and legally blind. Further review revealed Comprehensive Assessment Drug Profile physician order dated 01/13/2011 with diagnosis: End stage cerebrovascular accident; clean peg site with normal saline, apply treatment as ordered, cover with dry dressing daily as needed. 38. Medication pass at 1 p.m. on 3/21/2011 with an unlicensed facility staff member #4 found that resident #4's medication Bultalb ASA (aspirin) was being crushed by the unlicensed staff member. The staff member stated at 1:15 p.m. on 3/21/2011 that resident #4 had a peg tube and that the facility was providing his medication through the tube. Staff #4 said that medications were given by himself and staff #3, both of 14 whom are unlicensed personnel, therefore not qualified to provide any type of feeding or medication administration via tube. 39. The owner (not a licensed health care provider) came during this time and told staff member #4 that resident did not need the Bultalb ASA. Interview with the owner at this time verified unlicensed staff provided medications via tube to this resident, including "as needed" orders. The facility owner alleged at this time that hospice staff provide the resident the feedings via tube, although record review indicated the resident had an order to receive Boost via bolus tube feeding three times a day and record reviews indicate hospice staff were in the facility with the resident only once a day, at most. Review of the current hospice care plan for this resident revealed medication administration and tube feedings were not included with hospice services. 40. Based upon surveyor observations of this resident on 3/21/11 from 9:30 AM until 6:30 PM, the resident was not fed via the bolus. The hospice folder had a letter from resident #4's son giving the owner (staff #2) authorization to feed resident #4 dated 6/10/2010. The facility staff members could not provide any information as to who was providing three feedings per day to resident #4, although interview with caregiver #4 on 03/22/2011 at 10:31 a.m. revealed resident #4 had been 15 transferred to the hospital for peg tube change on January 15, 2011 as the first peg tube had clogged. 41. Rule 58A-5.019(2) (b), Florida Administrative code, provides as follows: “(b) All staff shall be assigned duties ‘consistent with his/her level of education, training, preparation, and experience. Staff providing services requiring licensing or certification must be appropriately licensed or certified. All staff .shall exercise their responsibilities, consistent with their qualifications, to observe residents, to document observations on the appropriate resident’s record, and to. report the observations to the resident’s health care provider in accordance with this rule chapter.” 42. Rule 58A-5.0181(1) (k), Florida Administrative Code, provides that a facility holding a standard or a limited nursing license cannot admit or continue to care for a resident who needs assistance with tube feeding. 43. Rule 58A-5.0181(4)(c), Florida Administrative . Code, allows a terminally ill resident who no longer meets the criteria for continued residency to continue to reside in the facility if the “resident qualified for, is admitted to, and consents to the services of a licensed hospice which coordinates and ensures the provision of any additional care and services that may be needed; ... and an interdisciplinary care plan is developed and implemented by a licensed hospice in consultation 16 with the facility. The facility staff may provide any nursing service permitted under the facility’s license....” 44. Rule 58A~5.031(1) (m), Florida Administrative Code, provides that a facility with a limited nursing license may provide any nursing service permitted within the scope of the nurse’s license for hospice patient. 45. Only a licensed nurse may feed and administer medication to a resident residing in an ALF who is on hospice via a PEG tube. This task is a nursing skill that requires specific knowledge of the human body for proper positioning of the resident and establishment of PEG tube placement to ensure the tube has not dislodged or clogged. Residual of stomach contents must be checked to determine if feeding was digested. Administering a feeding without this procedure performed first will result in coughing and choking, leading to aspiration into the lungs, which. results in pneumonia and perhaps demise. With regard to medication, after crushing permissible tablet forms and diluting with water, patency must be determined prior to and after administering medication. This is done by flushing with a specific amount of water, usually 30 cc’s. The flush after the medications are administered to allow the medications to flow into the stomach, and to prevent the medications from sitting in the PEG tube. This is a nursing skill that places the resident at imminent risk of serious physical harm if performed by one 17 who lacks knowledge and is not trained properly. Allowing unlicensed staff to feed and administer medication to a resident on hospice via a PEG tube places that resident at imminent danger or threat of serious physical or emotional harm. 46. Based on the foregoing facts, Ana Home Care violated Rule 58A~5.019(2) (b),. Florida Administrative Code, and Rule 58A- 5.0182, Florida Administrative Code, Rule 58A-5.0181(1) (k), Florida Administrative Code, Rule 58A~-5.0181(4) (c), Florida Administrative Code, Rule 58A-5.031(1) (m), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $5,000.00, and which gives rise to the revocation of the assisted living facility license (License number: 11559]. COUNT _IV ANA HOME CARE FAILED TO UTILIZE THE NURSE CONTRACTED FOR NURSING SERVICES AND FAILED TO ENSURE THAT NURSING SERVICES ARE PROVIDED TO THOSE FACILITY RESIDENTS NEEDING NURSING SERVICES. RULE 58A-5.031(2)&(3), FLORIDA ADMINISTRATIVE CODE (STAFFING STANDARDS) CLASS I VIOLATION 47. AHCA re-alleges and incorporates paragraphs (1) through (5) as if fully set forth herein. 48. A licensure survey was conducted on March 21, 2011 and March 22, 2011. Based on observations, record review, and 18 interview, it was determined that the facility failed to utilize the nurse contracted on file for Limited Nursing Services (LNS) to administer stage 4 sacral wound care treatment, Central Venous Pressure site Care (CVP), Foley Catheter Care, Percutaneous Endoscopic Gastrostomy (peg) tube feedings, and medications for 2 of 7 (Resident #1 and Resident #4) sampled residents. Moreover, the facility failed to ensure that nursing services were provided to the residents needing nursing services. The facility failed to provide skilled nursing services to Resident #1 who had a stage IV pressure ulcer; care of central venous pressure dressing; provision of Foley catheter care, and provision of oxygen, as ordered by a physician. The facility failed to provide skilled nursing services to Resident #4 relating to administration of nutrition and medications via a PEG tube. The findings include the following. 49. Based upon record review, the facility had contracted with a registered nurse (RN) to provide limited nursing services. Although this contract was in effect since 9/1/10 and facility residents #1 and #4 had significant clinical conditions requiring skilled nursing services, there was no evidence the registered nurse was providing services to any facility resident under’ an LNS contract. Facility record review also indicated there were no residents on an LNS log. This RN verified in an interview at approximately 11 AM on 3/21/11 that LNS services 19 were not being provided to facility residents and LNS required documentation had not been completed and was not available for any facility resident. 50. Record review revealed resident #1 was admitted to the assisted living facility (ALF) on 01/16/2011 based on the admission log with Dementia and Stage 2 Pressure Ulcer (AHCA form 1823) dated 1/16/2011. Based upon record review and interview with the facility contracted nurse on 3/22/11 at approximately 11 AM, there was no documentation of caring for .the resident's stage II pressure ulcer prior to hospitalization on 2/4/11 (a period of over two weeks without documented wound care). 51. On 02/04/2011, resident #1 was transferred to the hospital with flu-like symptoms and returned to the ALF on 02/07/2011. On 02/09/2011, resident #1 was transferred to the hospital with a diagnosis of diarrhea and returned to the assisted living facility on 02/18/2011. “the facility had no documentation regarding wound care orders and services that were provided to resident #1 between 1/16/2011 to 2/18/2011. 52. On 02/19/2011, resident #1 was admitted to a home health agency with diagnoses: Osteomyelitis (an infection of the bone), Decubitus Stage 4 pressure ulcer, Atrophy Gastritis without Hemorrhage, and Alzheimer's disease. On 2/28/11 (over a week after the resident returned to the facility with a stage IV 20 pressure ulcer), resident #1 was finally admitted to hospice care with diagnoses: End stage Cardiovascular Artery Disease, Dementia, Alzheimer's. Disease and Sacral Decubitus stage 4. The home health Plan of Care dated 02/19/2011 revealed pressure ulcer stage 4 on sacrum that measures 6.5cmx 5.0cm x 1.0cm, 3cm undermining from 10 to 6 0 ' clock. 53. Observation on 03/22/2011 at 7:10 a.m. revealed a cachetic female resident who looks pale and weak. The resident's legs were elevated while sleeping on a special mattress with evidence of breathing difficulty (dyspnea). The left leg was more swollen than the right leg. An indwelling Foley catheter bag without urine drainage and brown sediments in the tubing and Foley bag was observed. 54. Observation of resident #1 on 03/22/2011 at 10:15 aM by a nurse surveyor revealed dark sacral bed with full thickness tissue loss and more than moderate drainage on the dressing that was removed for observation. Observation on 03/22/2011 at 10:15 a.m., revealed central venous pressure (CVP) dressing with the date 03/15/2011. Record review found that the facility did not have orders and instructions for CVP site dressing. Based upon record review, it could not be determined how the CVP was being care for. Based upon interview with the facility contracted nurse on 3/22/11 at approximately 11 AM, skilled care was to provide changing to the CVP dressing once every three days, 21 although the dressing was dated as last being changed on 3/15/11 (one week prior). 55. Observation on 03/22/2011 at 10:15 a.m. revealed resident was lying on the Foley catheter tubing. ALF staff. was informed and resident was repositioned. Interview with the ALF aide on 03/22/2011 at 8:02 a.m. revealed the Foley bag had been emptied by the certified nursing assistant from hospice care that morning at 6:30 a.m. Based upon record review, there was no order within the facility indicating when or by whom the catheter tubing should be changed (although the standard of practice is generally at least monthly). There was no indication anywhere in the record for resident #1 when the tubing was last changed, for this catheter that had been in place for an undetermined amount of time. (There was no order found for initial insertion of the Foley catheter.) 56. In addition, the facility did not follow orders for provision of oxygen to resident #1. There was a physician order dated 02/28/2011 for oxygen at 2 liters (L)/minute via nasal canula. Multiple observations on 03/22/2011 of this resident revealed no oxygen was provided, as ordered, to this debilitated resident. Times of these observations include: 7:10 a.m., 8:36 a.m., 10:15 a.m., 12:22 p.m., and to 1:41 p.m. The resident was observed at these times to have irregular breathing. 57. The Hospice Registered Nurse assessment visit form for 22 resident #1: dated 03/15/2011 revealed wound measurement 7 centimeters (cm) x 8.2cm x 3.6cm, an increase in size since the previous measurement, indicating wound worsening. The Infectious Disease Treatment (IDT) care plan dated 2/28/2011 revealed resident #1 lost 22 pounds in the last month. 58. Interview with the facility contracted registered nurse (RN; staff #5) on 03/22/2011 at 11:50 a.m. revealed resident #1 did return to the facility from the hospitalization with a wound that had worsened. She stated the resident required vacuum and antibiotic therapy at one point for the wound. 59. Interview with the registered nurse from hospice on 03/22/2010 at 12:28 p.m., revealed he was in a meeting all day and he would visit the resident later in the day. The RN would not state when asked what the physician order was for the frequency of the CVP site dressing change. The surveyor at this time made a second request for the RN assessment notes and current physician orders since the resident had several significant changes at the ALF. Documents were not received prior to leaving the facility at 1:47 p.m. on 3/22/11. 60. Record review of resident #4 medical record revealed resident was admitted to the assisted living facility on 11/27/09 with diagnoses of dementia and legally blind. The agency for healthcare form 1823 revealed resident #4 required total assistance on admission for all activities of daily living 23 which include ambulation, bathing, dressing, eating, grooming, toilet, and transfer, preparing meals, and daily oversight of his well-being. Diet: pureed, nectar thick. 61. Review of medical records revealed a physician order dated 01/25/2010 to refer resident to hospice services: status post cerebrovascular accident, status post myocardial infarction, senile dementia, Percutaneous Endoscopy Gastrostomy tube (PEG), and legally blind. Further review revealed Comprehensive Assessment Drug Profile physician order dated 01/13/2011 with diagnosis: End stage cerebrovascular accident; clean peg site with normal saline, apply treatment as ordered, cover with dry dressing daily as needed. 62. Medication pass at 1 p.m. on 3/21/2011 with an unlicensed facility staff member #4 found that resident #4's medication Bultalb ASA (aspirin) was being crushed by the unlicensed staff member. The staff member stated at 1:15 p.m. on 3/21/2011 that resident #4 had a peg tube and that the facility was providing his medication through the tube. Staff #4 said that medications were given by himself and staff #3, both of whom are unlicensed personnel, therefore not qualified to provide any type of feeding or medication administration via tube. 63. The owner (not a licensed health care provider) came during this time and told staff member #4 that resident did not 24 need the Bultalb ASA. Interview with the owner at this time verified unlicensed staff provided medications via tube to this resident, including "as needed" orders. The facility owner alleged at this time that hospice staff provide the resident the feedings via tube, although record review indicated the resident had an order to receive Boost via bolus tube feeding three times a day and record reviews indicate hospice staff were in the facility with the resident only once a day, at most. Review of the current hospice care plan for this resident revealed medication administration and tube feedings were not included with hospice services. 64 Based upon surveyor’s observations of this resident on 3/21/11 from 9:30 AM until 6:30 PM, the resident was not. fed via the bolus. The hospice folder had a letter from resident #4's son giving the owner (staff #2) authorization to feed resident #4 dated 6/10/2010. The facility staff members could not provide any information as to who was providing three feedings per day to resident #4, although interview with caregiver #4 on 03/22/2011 at 10:31 a.m. revealed resident #4 had been transferred to the hospital for peg tube change on January 15, 2011 as the first peg tube had clogged. 65. The facility allowed unlicensed staff to administer medication to a resident on hospice via a PEG tube thus placing the resident in imminent danger or threat of serious physical or 25 emotional harm. 66. Only a licensed nurse may feed and administer medication to a resident residing in an ALF who is on hospice via a PEG tube. This task is a nursing skill that requires specific knowledge of the human body for proper positioning of the ‘resident and establishment of PEG, tube placement to ensure the tube has not dislodged or clogged. Residual of stomach contents must be checked to determine if feeding was digested. Administering a feeding without this procedure performed first will result in coughing and choking, leading to aspiration into the lungs, which results in pneumonia and perhaps demise. With regard to medication, after crushing permissible tablet forms and diluting with water, patency must be determined prior to and after administering medication. This is done by flushing with a specific amount of water, usually 30 cc’s. The flush after the medications are administered to allow the medications to flow into the stomach, and to prevent the medications from sitting in the PEG tube. This is a nursing skill that places the resident at imminent risk of serious physical harm if performed by one who lacks knowledge and is not trained properly. Allowing unlicensed staff to feed and administer medication to a resident on hospice via a PEG tube places that resident at imminent danger or threat of serious physical or emotional harm. 67. Based. on the foregoing facts, Ana Home Care violated 26 Rule 58A-5.031(2)&(3), Florida Administrative Code, herein classified as a Class I violation, which warrants an assessed fine of $5,000.00, and also gives rise to the revocation of the assisted living facility license [License No.: 11559]. CLAIM FOR RELIEF WHEREFORE, the Agency requests the Court to order the following relief: 1. Enter a judgment in favor of the Agency for Health Care Administration against Ana Home Care on Counts I through Iv. ) 2. Assess an administrative fine of $20,000.00 against Ana Home Care based on Counts I through IV for the violations cited above. 3. Revoke the assisted living facility license [License No.: 11559] of Ana Home Care based on Counts I through IV for the violations cited above. 4. Assess costs related to the investigation and prosecution of this matter, if the Court finds costs applicable. 5. Grant such other relief as this Court deems is just and proper. Respondent is notified that it has a right to request an administrative hearing pursuant to Sections 120.569 and 120.57, 27 Florida Statutes (2010). Specific options for administrative action are set out in the attached Election of Rights. All requests for hearing shall be made to the Agency for Health Care Administration, and delivered to the Agency Clerk, Agency for Health Care Administration, 2727 Mahan Drive, MS #3, Tallahassee, Florida 32308. RESPONDENT IS FURTHER NOTIFIED THAT THE FAILURE TO RECEIVE A REQUEST .FOR A HEARING WITHIN TWENTY-ONE (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. IF YOU WANT TO HIRE AN ATTORNEY, YOU HAVE THE RIGHT TO BE REPRESENTED BY AN ATTORNEY IN THIS MATTER Lourdes A. Naranjo, lane oe Fla. Bar No.: 997315 Assistant General Counsel Agency for Health Care Administration 8333 N.W. 53° Street Suite 300 Miami, Florida 33166 28 Copies furnished to: Field Office Manager Agency for Health Care Administration 8333 N. W. 537° Street - Suite 300, Miami, Florida 33166 (U.S. Mail) CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing has been furnished by U.S. Certified Mail, Return Receipt Requested to Armando Hidalgo, Administrator, Ana 1 a Care, 20555 S. W. 187 Avenue, Miami, Florida 33187 on this Zi -_ day of fee" , 2012. Vourdes A. Naranjo, Esq. 29 STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION RE: Ana Home Care, Inc. d/b/a Ana Home Care AHCA No.: 2011003160 ELECTION OF RIGHTS This Election of Rights form is attached to a proposed action by the Agency for Health Care Administration (AHCA). The title may be Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. Your Election of Rights must be returned by mail or by fax within 21 days of the day you receive the attached Notice of Intent to Impose a Late Fee, Notice of Intent to Impose a Late Fine or Administrative Complaint. If your Election of Rights with your selected option is not received by AHCA within twenty- one (21) days from the date you received this notice of proposed action by AHCA, you will have given up your right to contest the Agency’s proposed action and a final order will be issued. (Please use this form unless you, your attorney or your representative prefer to reply according to Chapter 120, Florida Statutes (2006) and Rule 28, Florida Administrative Code.) PLEASE RETURN YOUR ELECTION OF RIGHTS TO THIS ADDRESS: Agency for Health Care Administration Attention: Agency Clerk 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308. Phone: 850-412-3630 Fax: 850-921-0158. PLEASE SELECT ONLY 1 OF THESE 3 OPTIONS OPTION ONE (1) I admit to the allegations of facts and law contained in the Notice of Intent to Impose a Late Fine or Fee, or Administrative Complaint and I waive my right to object and to have a hearing. I understand that by giving up my right to a hearing, a final order will be issued that adopts the proposed agency action and imposes the penalty, fine or action. OPTION TWO (2) 1 admit to the allegations of facts contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, but I wish to be heard at an informal proceeding (pursuant to Section 120.57(2), Florida Statutes) where I may submit testimony and written evidence to the Agency to show that the proposed administrative action is too severe or that the fine should be reduced. OPTION THREE (3)____—s—s- dispute the allegations of fact contained in the Notice of Intent to Impose a Late Fee, the Notice of Intent to Impose a Late Fine, or Administrative Complaint, and I request a formal hearing (pursuant to Subsection 120.57(1), Florida Statutes) before an Administrative Law Judge appointed by the Division of Administrative Hearings. PLEASE NOTE: Choosing OPTION THREE (3), by itself, is NOT sufficient to obtain a formal hearing. You also must file a written petition in order to obtain a formal hearing before the Division of Administrative Hearings under Section 120.57(1), Florida Statutes. It must be received by the Agency Clerk at the address above within 21 days of your receipt of this proposed administrative action. The request for formal hearing must conform to the requirements of Rule 28- 106.2015, Florida Administrative Code, which requires that it contain: 1. Your name, address, and telephone number, and the name, address, and telephone number of your representative or lawyer, if any. 2. The file number of the proposed action. 3. A statement of when you received notice of the Agency’s proposed action. 4. A statement of all disputed issues of material fact. If there are none, you must state that there are none. Mediation under Section 120.573, Florida Statutes, may be available in this matter if the Agency agrees, License type: (ALF? nursing home? medical equipment? Other type?) Licensee Name: License number: Contact person: Name Title Address: Street and number City Zip Code Telephone No. Fax No. Email(optional) Thereby certify that I am duly authorized to submit this Notice of Election of Rights to the Agency for Health Care Administration on behalf of the licensee referred to above. Signed: Date: Print Name: Title: Late fee/fine/AC US Postal Servicem (Domestic ‘Mail Only; No Insurance | For.delivary information visit our: webs O FFICIA Postage | $ Caitifled Fee Raturn Recalpt Feo (Endoraement Required) Restricted Delivery Fea {Endorsement Required) Total Postage & Fees $ 7009 0080 O000 O58 1213 BS -Rorin:3800, “August "3006" PS Form 381 1, February 2004 : SENDER: COMPLETE THIS SECTION CERTIFIED MAIL. REIS COMPLETE THIS SECTION ON DELIVERY Domestic Return Receipt GAnin wd) c Af 102595-02-M-1840 i handise

Docket for Case No: 11-002434

Orders for Case No: 11-002434