STATE OF FLORIDA

AGENCY FOR HEALTH CARE APMINISTRATION

STATE OF FLORIDA, AGENCY FOR

HEALTH CARE ADMINISTRATION,

Petitioner,

vs. Case Nos. 2011004768 (Fine)

2011004769(Cond.)

GAINESVILLE COUNCIL ON AGING, INC., d/b/a GAINESVILLE HEALTH CARE CENTER,

Respondent

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ADMINISTRATIVE COMPLAINT

COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration ("the Agency"), by and through the undersigned counsel, arid files this Administrative Complaint against the Respondent, Gainesville Council on Aging, Inc., d/b/a Gainesville Health Care Center ("the Respondent"), pursuant to sections 120.569 and 120.57, Florida Statutes, and alleges:

NATURE OF THE ACTION

This is an action to impose an administrative :fine in the amount of Two thousand five hundred dollars ($2,500.00) and assign conditional licensure status commencing January 28, 2011 and ending April 18, 2011.

PARTIES

1. 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 II, and 400, Part II Florida Statutes, and Chapter 59A-4, Florida Administrative Code.

2. The Respondent was issued a license (License Number 1568096) by the Agency to

   
   

   Filed August 25, 2011 1:25 PM Division of Administrative Hearings

   
   

   operate a nursing home located at 1311 SW 16th Street, Gainesville, Florida 32608, was at all times material times required to comply with all applicable regulations, statutes and rules.

   COUNT I (Tag N216)

   
   

3. Under Florida Jaw, 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 shalJ treat such residents in accordance with the provisions of that statement. The statement shall assure each resident the following . .. (l) 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 II of Chapter 408, any 'of the

   
   

   following conditions shall be grounds for action by the Agency against a licensee: {l) An intentional or negligent act materially affecting the health or safety of residents of the facility. § 400.102(1), Fla. Stat.

5. On January 28, 2011, the Agency conducted a complaint (CCR# 201100970) investigation of the Respondent and its facility.

6. That based upon observation, the review of records, and interview, Respondent failed to ensure the provision of adequate and appropriate health care ·and protective and support services with established and recognized practice standards within the community, and with rules as adopted by the Agency where Respondent initially failed to provide safe bedding equipment for a resident and subsequently failed to provide adequate supervision, assistive devices, or other interventions after the resident was found with the upper torso off the bed and head on the floor, the same being contrary to the requirements of law.

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-7 7. That Petitioner's representative reviewed Respondent's records related to resident

j number one (1) during the survey and noted as follows;

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1. The resident's history and physical reflected a seventy-three (73) year old who weighs over two hundred (200) pounds.

2. The resident was admitted to the facility on January 24, 2011 from the hospital.

   
   

3. On January 26, 2011, the resident fell from the resident's bed sustaining a laceration to the lower lip and facial bruising.

4. The resident was transported to the hospital as a result of this fall.

1. That Petitioner's representative interviewed Respondent's certified nursing assistant on January 28, 2011 regarding resident number (1) who indicated as follows:

   1. She was assigned to the resident on January 26, 2011.

      
      

   2. Upon arriving for her shift at 3:00 PM, she did rounds and noted that the resident was sleeping,

   3. At 4:00 PM, she again checked on the resident whose adult child was at the bedside.

   4. That between 5:15 and 5:30 PM, she parked the dinner cart and heard coughing coming from room 416.

   5. She went into the room to find the resident half on and half off the bed.

      
      

   6. The resident was on a "low air mattress" on a bed frame that did not have side rails.

   7. She repositioned the resident and notified the evening registered nurse supervisor that the resident needed a new bed due to finding the resident half on and half off the bed.

      
      

   8. The registered nurse supervisor stated to that she would call housekeeping.

      
      

   9. Twenty (20) to thirty (30) minutes later, she was feeding a resident across the hall when she heard moaning sounds coming from outside the room of resident number one (I).

   10. She was accompanied by certified nursing assistant number two (2) who was also

       
       

       feeding a resident in the same room.

       
       

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   11. They went into room 416 and found resident number one (I) face down on the floor.

2. That Petitioner's representative interviewed Respondent's 3-11 shift registered nurse

   
   

   supervisor on January 28, 2011 regarding resident number (I) who indicated as follows:

   
   

   1. At 6:45<PM on January 26, 2011, she received a call that the resident had fallen ry

      
      

      out ofbed in room 416.

      
      

   2. She arrived in the room to find the resident face down on the floor bleeding from the face.

      C. Emergency Medical Services (EMS) was called.

      
      

      1. At 5:50 PM on January 24, 2011, a certified nursing assistant told her that the resident needed a new bed.

      2. At that time, she paged housekeeping and asked that a new bed be delivered to the fourth floor.

      3. Housekeeping responded quickly, but the resident fell out of bed before the bed change could be made.

3. That Petitioner's representative interviewed Respondent's housekeeping employee number one (I) on January 28, 2011 regarding resident number (I) who indicated as follows:

   
   

   1. A registered nurse supervisor did call to have a new bed with side rails brought up

      
      

      to resident number one (1).

      
      

   2. After the call, another bed was immediately located and prepared to be taken to the 4th floor.

   3. Upon arriving on the 4th floor with the bed, they were told that the resident had just fallen.

4. That Petitioner's representative, on January 28, 2011, observed and measured the bed and mattress utilized by resident number one (1) on January 24 or 26???, 2011, and noted as follows:

   1. The mattress, a "Microcare by Invacare," is a low air mattress which is rented and does not belong to the facility.

   2. The mattress m asures thirty-eight and on-half inches (38.5) across.

      
      

   3. The actual bed frame measured thirty-five (35) inches across.

      
      

   4. No side rails were on the bed frame or in use at the time of the fall.

      
      

5. That Petitioner's representative interviewed Respondent's administrator on January 28, 2011 regarding resident number (1) who indicated as follows:

   1. The administrator confirmed that the bed frame and low air mattress that was observed and measured by Petitioner's representative was in use by the resident at the time of the resident's fall. The Invacare low air mattress is made of a synthetic parachute type fabric. The bed frame was metal.

6. That Petitioner's representative reviewed hospital records related to resident number one

   
   

   (1) during the survey and noted that the resident sustained a hematoma on the left side of the forehead and a small laceration to the lower lip.

7. That the above reflects Respondent's failure to adequate and appropriate health care and

   
   

   protective and support services with established and recognized practice standards within the

   
   

   community, and with rules as adopted by the Agency by Respondent's failure to:

   
   

   1. Assure that the bedding equipment supplied for resident number one (I) was safe for use including, but not limited to, assuring that the mattress fit the frame;

   2. Assure that side rails be reviewed for appropriateness to assure the bed safety of resident number one (1).

   3. Assure that adequate supervision or other appropriate intervention was undertaken once Respondent knew that resident number one (1) had partially fallen from the bed supplied_ to the resident and prior to the substitution of safe bedding equipment for the resident.

8. That the Agency determined that these failures compromised the resident's ability to

   
   

   maintain or reach his or her highest practicable physical, mental, and psychosocial well-being, as

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   defined by an accurate and comprehensive resident assessment, plan of care, and provision of services and cited this deficient practice as an Isolated State Class II deficiency. •."' ·•

   WHEREFORE, the Agency seeks to impose an administrative fine in the amount of

   
   

   $2,500.00 against Respondent, a skilled nursing facility in the State of Florida, pursuarit to §

   
   

   400.23(8)(b), Florida Statutes (2010).

   
   

   COUNT II

   
   

9. The Agency re-alleges and incorporates paragraphs one (I) through five (5) and Count I of this Complaint as if fully set forth herein.

10. Based upon Respondent's cited State Class II deficiency, 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)(a), Florida Statutes (2010).

WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration,

intends to assign conditional licensure status to Respondent commencing January 28, 2011 and

ending April 18, 201I.

Respectfully submitted thisUday of July, 2011.

J. Walsh II, Esquire

. · ar. No. 566365

"'- ency for Health Care Admin. 525 Mirror Lake Drive, 330G St. Petersburg, FL 33701 727.552.1947 (office)

NOTICE

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The Respondent has the right to request a hearing to be conducted in accordance,,wJthi Sections 120.569 and 120.57, Florida Statutes, and to be represented by counsel or.·other. qualified representative. Specific options for the administrative action are set oufwithin 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 Administrative Complaint and Election of Rights Form were served by U.S. Certified Mail, Return Receipt No. 7009 0960 0000 3709 6055 to Jamie Lynn Gilrain, Administrator, Gainesville Health Care Center, 1311 SW 16tll Street, Gainesville, Florida 32608 and by U.S. Mail to David C. Willis, Registered Agent for

Gainesville Council on Aging, Inc., 300 South Orange Avenue, Suite 1400, Orlando, Florida

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· 32801 on this_2Q_ day of July, 2011:

Copy: Kris Mennella, Field Office Manager

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Docket for Case No: 11-004378

Orders for Case No: 11-004378