_ STATE OF FLORIDA AGENCY FOR HEALTH CARE ADMINISTRATION STATE OF FLORIDA, AGENCY FOR HEALTH CARE ADMINISTRATION, | Petitioner, vs. AHCA Nos. 2012009477 . ; : ' 2012009489 JACKSONVILLE FACILITY OPERATIONS, LLC d/b/a CONSULATE, HEALTH CARE OF JACKSONVILLE, Respondent. / ADMINISTRATIVE COMPLAINT COMES NOW the Petitioner, State of Florida, Agency for Health Care Administration (hereinafter “the Agency”) by and through its undersigned counsel, and files this Administrative Complaint against the Respondent, Jacksonville Facility Operations, LLC d/b/a Consulate Health Care of Jacksonville (hereinafter “the Respondent”), pursuant to Sections 120.569 and 120.57 Florida Statutes (2011), and alleges: ) NATURE OF THE ACTION This is an action against a skilled nursing facility to impose an administrative fine of $35,000.00 based upon three Class I violations, assess a six-month survey cycle.and survey cycle fine of $6,000.00, and assign conditional licensure status beginning on August 11, 2012. PARTIES 1. The Agency is the licensing and regulatory authority in Florida that oversees skilled nursing facilities, commonly known as nursing homes, and enforces the applicable federal ‘Tegulations and state statutes and rules governing such facilities. Chs. 408, Part Il, and 400, Part Il, Fla. Stat, (2012), Chs. 59A-35 and 59A-4, Fla. Admin. Code. As part of its authority, the Filed October 10, 2012 10:59 AM Division of Administrative Hearings Agency may issue emergency orders, including an immediate moratorium on admissions of residents, when the circumstances dictate this action. §§ 120.60(6), 408.814(1), Fla. Stat. (2012), 2, The Respondent was issued a license by the Agency to operate a 116-bed skilled nursing facility in Florida located at 4101 Southpoint Drive East, Jacksonville, Florida 32216 : (hereinafter “the Facility”), and was at all material times required to comply with all applicable federal regulations and state statutes and rules governing such facilities. - oo : COUNT I Intentional or Negligent Act Materially Affecting Resident Health or Safety 3, Under Florida law, the Agency is authorized to take action against a skilled ‘nursing facility for an intentional or negligent act materially affecting the health or safety of residents of the facility. § 400.102(1), Fla. Stat. (2012). . Resident Rights 4, 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, § 400.022(1), Fla. Stat. (2012), The statement shall assure each resident ... 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 tesidetit 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, (2012), 5. The Agency conducted a survey of the Respondent and its Facility on or about August 7-11, 2012. 6. Based upon observation, record review and staff interview, 8 of 32 sampled state members (#5, #11, #14, #17 #23, # 26, #27 29) failed to adhere to an infection control program designed to protect residents from health care associated infections, . ‘7, The Facility’s staff failed to: (1) Use personal protective equipment for a patient . with "resistant" Clostridium Difficile infection (C-Diff) a diarrheal infection: (2) Use dedicated medical equipment or clean shared medical equipment after use with a resident with a C. Diff infection, (3) Place residents with C. Diff infection in a private room or cohort with similar infection. (4) Use proper hand hygiene during wound care to prevent cross contamination, (5) Dispose of a contaminated gown appropriately. (6) Post signage for contact isolation in a location obvious to staff and visitors. 8. These practices placed residents at risk for acquiring serious multi-drug resistant infections such as pseudomembranous colitis (inflammation of the colon due to infection), toxic megacolon (extreme dilation ofthe colon), perforations of the colon, and sepsis, and death. 9, A record. review of the medical record for Resident #40 revealed laboratory specimens collected two times on 7/17/12 were positive for C-Diff (Clostridium Difficile is a spore-forming, Gram positive anaerobic bacillus that produces two exotoxins: toxin Aand toxin. B and is a common cause of antibiotic- associated diarthea.), 10, A review of the physician's progress notes revealed that the resident had "resistant" C-Diff. 11. On 8/8/12 at 10:10 am, a Certified Nursing Assistant (CNA #14) was observed standing next to the bed of Resident #40, without wearing Personal Protection Equipment (PPE). Resident #40 was on contact isolation for C-Diff, 12. ° During an interview with CNA #14 on 8/8/12 at 10:12 am for Resident # 40, it : was revealed that she did not have to wear PPE (gown or gloves) because she was not at the bedside of the resident who was diagnosed with C-Diff, 13. She stated that she was not changing the resident. CNA #14 stated that Resident #40 was not on isolation and the room-mate (Resident #271) of Resident #40 was on contact isolation for C-Diff. She stated that she floated and did not know the residents, , 14. CNA #14 stated that she was watching the room-mate (#271) of Resident #40 to ensure that he did not get up and injure himself. CNA #14 revealed that she did not realize that Resident #40 was on contact isolation for C-Diff. 1S. 6A review of the medical record for Resident #271 (room-mate) revealed he ‘was admitted to the Facility on 7/25/12 with pneumonia, 16.- There was no evidence in the medical record that Resident #271 had C-Diff,' but he was shating the same room with Resident #40 who had resistant C-Diff. 17, On 8/8/2012 at 3:45 PM, CNA #23 was observed as she wore Personal Protective Equipment (PPE) consisting of gown, mask and gloves in front of. . 18. During an interview with CNA #23 at the time of the observation, it was revealed that she vas aware of the room as an isolation room with a C-Diff infection. 19, CNA #23 was observed as she took the blood pressure cuff-and thermometer into the contaminated room. 20, At 3:50 PM CNA #23 was observed; CNA #23 left the room and used antiseptic hand rub to clean her hands, rather than using soap and water to wash her hands. ai. CNA did not clean the shared blood pressure cuff or thermometer, 22, CNA #23 walked into other rooms in the hallway using the same shared blood pressure cuff and thermometer from room to room. e e 23, During an interview with the Interim Director of Nursing (DON)nfection Control Nurse on. 8/9/12 at 3:58 PM, it was revealed that she thought there were 2 to 3 cases of . C-Diff in the building and it was a “guesstimate. . 24, The IDON stated that they tracked infections by completing an epidemiology worksheet considering predisposing factors to determine if infections were community or facility acquired, She further stated that staff development was conducting audits and observations of hand-washing. 25. Observation of Resident #40 on 8/10/12, at 8:00 AM revealed that he was lying in bed. 26. CNA#27 picked up the resident's breakfast tray from the food. cart. 27. CNA #27 entered the resident's room. and placed the breakfast tray on the bedside table. , . . 28. CNA #27 leaned over the resident's bed rails touching the bed rails to set the . resident up to eat. 29.» CNA #27 did not don any PPE before entering the room, such as a yellow gown. from the utility cart outside the door or place a paix of gloves on. . 30. CNA #27 came out of the room, picked up a pair of gloves and placed the gloves on both hands without washing her hands with soap and water. 31. CNA #27 returned to the resident's bedside to assist him to sit up and to set up food items on the tray for him to use, 32, CNA #27 was informed about the C-Diff infection by the surveyor and informed that she needed to wash her hands with soap and water since the antiseptic foam was not effective against C-Diff. 33. During an interview with CNA #27 on 8/10/12 at 8:05 am, it was revealed that she was supposed to put on PPE, such as gloves and gowns before entering Resident #40’ s room, 34, She stated that she touched the bedside table and bed rail when she spoke with . Resident #40. ‘ | 35. CNA #27 was asked if Resident 40 used the bathroom. 36. She stated that Resident #271, room-mate of Resident # 40 used the bathroom. CNA #27 stated that Resident #271 did not have a C-Diff infection. ) 37, CNA #27 stated that at times she took Resident # 40 to the bathroom. 38. CNA #27 stated that both residents shared the same toilet. 39. There was no bedside commode observed in the residents room from, 8/6/12- 8/10/12 for Resident # 40 to use, 40. CNA #27 stated that she was going to tell the truth. 41. Observation of Resident #40 with Staff Nutse #17 on 8/10/12 at 9:58 AM revealed the resident was sitting in his wheelchair in the hallway near to his room. 42, Staff Nurse #17 demonstrated the resident's alarm system attached to his wheelchair, 43. Staff Nurse #17 lifted up the resident's right arm to demonstrate the alarm system. . equipment with a medication cup with pills in her bare hand. 44, Staff Nurse #17 retumed the cup to the medication cart and approached the resident again to demonstrate the alarm system attached to the rear of the wheelchair. 45.. Staff Nurse #17 entered the resident's room without PPE to demovstrate the bed alarm. She was observed making contact with the resident's bed linens, bed side rail, mattress and the alarm sensor equipment. 46. Staff Nurse #17 called ont to CNA #27 who was standing down the hallway on 8/10/12 at 10:11 AM and asked her to come down to the oom. 4, 48, rail, 49, 50. 3h Staff Nurse #17 asked the CNA to demonstrate the bed alarm in the room. CNA #27 entered the room of Resident #40 and was observed touching the side CNA #27 left the room and started to use antiseptic foam to clean her hands. She was xeminded to use soap and water for effective hand washing, A teview of the policy and procedure for contact precautions revealed contact precautions will be used for residents with known. or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident care activities that required touching the tesident's dry skin or indirect contact with environmental surfaces or resident care items in the resident's environment. 92, #20. 53. 34. orders, 55. 56. 57. On 08/08/12 at 10:30 AM, wound care observation was completed for Resident Nurse #5 was performing the dressing change. Prior to beginning the treatment, Nurse #5 reviewed the resident's treatment After review, Nurse #5 went to the room and washed her hands. Nurse #5 came out of the room and went to the side of her medication: cart, Nurse #5 reached into the trash receptacle to locate a trash bag to discard the soiled dressing. 58. 59, There were no extra trash bags available, Nurse #5 stated she would use the bedside trash can. 4 60. Nurse #5 returned to the resident's room and washed her hands. 6h Nurse #5 re-cheoked the treatment orders. 62.. Nurse #5 created an aluminum foil barrier on top of the wound treatment cart, 63. » Nurse #5 removed some clean gloves from a box of gloves, and placed the gloves : back in the box. 64, The nurse scratched the back of her head and removed clean gloves from the box of clean gloves and placed the gloves on top of the treatment cart without the barrier. 65, Nurse #5 was informed that she had just scratched her head and needed to perform hand hygiene. | 66, — Nurse #5 used hand antiseptic rub to clean her hands. 67. Nurse #5 removed the contaminated gloves from the top of the treatment cart and. discarded them. 68. Nurse #5 placed clean gloves on the aluminum foil barrier, * 69. Nurse #5 obtained 2 plastic medication cups from the top drawer of the treatment cart and placed them on the clean field. 70. — Nurse #5 placed the clean field on top of the resident's bedside table, 71, Nurse #5 did not gather the bandages for dressing, Nurse #5 stated, "I don't know what I am doing.” 72, — Nurse #5 returned to the treatment cart and gathered 4 X 4s and a roll of Kerlix and took them into the room, and placed them on top of the clean field. 723. The Kerlix (gauze) obtained fiom the treatment cart was open. Nurse #5 kept stating, "I don't know what I'm doing." | 74. — The unit manager was notified that Nurse #5 was overwhelmed and confused. 75. Nurse #11 came to the resident's room to perform the dressing change. 16. Nurse #11 went into a resident's room across the hall from the resident, and washed her hands. , Nurse #11 returned to the treatment cart, 78 Nurse #1 1 created an aluminum foil barrier to gather her supplies. 79. Nurse #11 placed the peroxide solution to cleanse the wound and the ointment to apply to the wound, into medication cups, Nurse #11 obtained dry 4 X 4s and Kerlix. . 80. Nurse #11 entered the resident's room and realized the resident was sitting in her wheelchair 81, Nurse #11 assisted the resident to pull down her pants to expose the wound. 82. Nurse #11 removed the resident's shoes and touched the bottom of the shoes and assisted the resident to the bed, 83. Nurse #11 went out to the treatment cart without performing hand hygiene and obtained a box of gloves by the top of the glove box with her finger inserted in the opening. 84. Nurse #11 was informed her that she had- touched the bottom of the resident's shoes and had not performed hand hygiene and had contaminated the box of gloves. 85. Nurse #11 disposed of the box of gloves, washed her hands and obtained another box of gloves, 86. “When Nurse #11 went to remove the old dressing from the resident's leg, Nurse #5 reached into her pocket and obtained a pair of scissors and placed them on the bedside table for Nurse #11 to use to remove the resident's dressing. 87. Nurse #5 was asked what the scissors had been used for and. where the scissors had come from. 88. Norse #11 informed Nurse #5 that the scissors needed to be sterilized (Sterilization requires heat or chemical agents). 89. Nurse #5 took the scissors to the resident's bathroom and washed them with soap and water in the sink and obtained alcohol pads off the medication’ cart to wipe the scissors, - 90. Nurse #5 was asked how she disinfected the scissors for residents with C-Diff and Methicillin Restraint Staphylococcus Aureus (MRSA). ) 91. She revealed she would use a pair of disposable scissors. Nurse #5 left the room to obtain a pair of disposable scissors. 92. Nurse #5 renamed with a suture removal kit because there were no disposable scissors in the building. 93. Nurse #11 utilized the scissors in the suture removal kit to.remove the dressing from the resident's leg, . "94, On 08/10/12 at 10;10 AM, morning care was observed for Resident #103. 95. The resident ‘was on contact isolation for MRSA infection at the gastrostomy site (G-tube), . 96. The G-tube was covered with a dry dressing, 97. The certified nursing assistant (CNA) # 26 performing the care revealed she had already cleaned the resident's torso and was about to begin perineal care. 98. CNA #26 cleansed the resident's perineal area with soap and water. 99. CNA #26 dried the area with a towel. 100. CNA #26 removed the glove from her tight hand and disposed of it in the red biohazards bag taped to the resident's bedrail and her left hand remained gloved. 101. CNA #26 reached under her isolation gown and reached in her right pocket with _ 10 her non-gloved hand and removed a packet of bantier cream. 102. CNA #26 squeezed some of the cream into her gloved hand. 103. CNA #26 placed the open packet of cream back into her pocket and obtained g clean glove and donned it on her right hand, 104. CNA #26 applied the cream to the resident's perineal-area, 105, CNA #26 positioned Resident #103 on her left side so that the resident's back could be observed. CNA #26 walked over to the left side of the bed and cleansed Resident #103's buttocks, 106. CNA #26 removed her right glove with her left hand and reached into her pocket with non-gloved hand and obtained the packet of barrier cream that she had placed in her pocket, CNA #26 applied the cream to the resident's buttocks, 107. These findings were discussed with the CNA. . 108. A xeview of the Hand washing Technique Policy and Procedure dated 01/07 revealed all personnel would wash their hands to remove dirt, organic material, and transient microorganisms to prevent the spread of infections. | . Hands must be washed: After contact with blood/body fluids Tn between resident contacts Before clean procedure After contact with contaminated items or surfaces After the removal of gloves 109. On 8/7/2012 at 3:27 PM, CNA #29 was observed on the 400 hallway when she dropped a clean gown that she had just retrieved from a covered clean linen cart on the floor. 110. CNA # 29 picked up the contaminated gown and returned the gown back on the covered clean linen cart. 11 U1, During an interview with CNA #29 on 8/7/12 at 3:29 PM, it was revealed that the CNA adiitted she dropped the gown on the floor and placed it back on the cart. 112, CNA-#29 stated that the normal process was to put items on the floor into a bag ‘and place in the dirty utility room. 113. During an interview with the Environmental Service Director on 8/7/12 at 3:30 PM, it was revealed that contaminated or dropped items on the floor should be placed in a bag and taken to the dirty utility room: 114. He stated it should never be returned to the clean linen cart. 15. The Environmental Service Director removed the cart from the hallway, 116. On 8/7/2012 at 9:20 AM, surveyor observed a cart containing PPE supplies by the door of Resident #184, . ; ) 117. The isolation sign on the top of ‘the cart that informs visitors and staff to stop before entering the room was obscured by a box of gloves, “118. An unidentified nurse who was in the hallway at the time was what resident the PPE cart belonged to and what kind of infection the resident had, 119. Staff responded that the resident had C-Diff and that surveyor should wear gloves before going into the room. 120. The sign was not posted on the door and if visitors so visitors could walk straight into the room without taking any precautions. 121, Observation of the PPE cart for Resident #40 on 8/8/12 at 10:18 AM revealed there was no posted sign to see the nurse before entering for Resident #40. 122. The sign was found taped to the top of the’ white plastic utility cart that contained gowns and masks. 12 123, A box of gloves was located on top of the sign, preventing anyone from seeing it, 124, During an interview with the IDON on 8/9/12 at 3:58 PM, it was revealed that . when residents were on isolation there should be a signage sign on the door for staff/visitors to stop. . . 125. - A review of the policy and procedure for identification of residents on isolation precautions with an effective date of 1/07, revealed isolation precautions requires the use of a stop sign to assist the healthcare worker and others in identifying the need for special precautions, ) 126. The deficiency was widespread, 127. Under Florida law, 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 cortection. § 400.023(8)(a), Fla, Stat. (2012). 128. Under Florida law, a class I deficiency is subj cot 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 ticensure inspection. A fine must be levied notwithstanding the correction of the deficiency. § 400.023(8)(a), Fla. Stat. (2012). Under Florida law, each day of violation constitutes a separate violation and is subject to a separate fine. § 408.813(1), Fla, Stat, (2012), 13 WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to impose an administrative fine of $15,000.00 against the Respondent. COUNT. Failure to Follow Physician Orders 129, Under Florida Jaw, all physician orders shall be followed as prescribed, and if not . followed, the reason shall be recorded on the resident’s medical record during that shift. Fla, Admin, Code 59A-4, 107(5). 130. The Agency conducted a survey of the Respondent and its Facility on or about August 7-11, 2012, ‘BL Based on observation, staff and family interviews, clinical xecord and policy and procedure review, the Facility failed to follow physician order's and implement safety measures for 1 of 8 sampled residents. (Resident #103) Resident #103 was in her room sitting alone in her wheelchair and the seatbelt was not in place and she fell to the foor, The resident was sent to the hospital emergency room where they determined the fall caused a fracture of her nose. 132, On 08/07/12 at 3:10 PM, an observation of Resident #103 revealed that the resident had a yellowish-green bruise to the left side of her face, 133. The resident was alert, but was not able to communicate, 134. On 08/09/12 at 2:20 PM, an interview with Resident #103: s daughter revealed that on 07/09/ 12 her sister found the resident on the floor at the facility. 135. She revealed she did not believe the wheelchair brakes wete on at the time her mother fell, because her mother did not have the stréngth to move the chair. 136. A review of Resident #103's clinical record revealed she was admitted to the facility on 01/21/12 with a readmission date of 01/30/12, - 137. The resident's admission diagnosis included pneumonia, type 2 diabetes without 14 complications, senile dementia, hypertension, edema, aphasia and gastrostomy (G-tube). 138. A review of the admission Minimum Data Set (MDS) assessment with _ Assessment Reference Date (ARD) of 02/09/12, Section B, revealed that the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood, 139. It also revealed the resident was totalling dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene, 140. Activities such as walking in the room or corridor did not occur, 141. Balance during walking, turning around and moving from seated to standing position did not occur, 142, The zesident's assessment revealed she had not had a fall 6 months prior to admission, and no falls since admission, . 143, A review of the quarterly MDS Assessment with an ARD of 04/27/12 revealed that the resident had no speech, was rarely or never understood by others and was rarely or never able to make herself understood, 144, It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. 145. Activities such as walking in the room or corridor did not occur, 146. Balance during walking, tuning around and moving from seated to standing position did not occur. oO 147. The assessment revealed the resident had not had a fall 6 months prior to admission, and no falls since admission. 148. Section P of the assessment revealed the resident had a trunk vestraint used daily 15 _ When up out of bed in chair. 149. A review of the physician's order dated 04/16/12 revealed an order for Resident #103 to have'a lap buddy when the resident was in, her wheelchair for fall precautions. 150. There was a clarification order dated 05/04/12 to apply a seatbelt to the whee)chair while the resident was out of bed due to senile dementia and muscle weakness. 151. The order included the release of the lap buddy every 2 hours and during supervised activities, and to check every 30 minutes. 152. A review of the Weekly Nursing Progress Form dated 07/05/12 revealed Resident #103 did not have restraints, and indicated the resident's plan of care was appropriate for the resident. . . 153. A review of the Treatment Records for May through July 2012 included the order written on 05/04/12 for the seatbelt on the wheelohait while out of bed due to senile dementia, muscle weakness and release every two hours during supervised activities and every 30 minutes revealed no documentation the seatbelt had.been implemented. 154. The July 2012 treatment record revealed the order was discontinued on 07/10/12, 155. The Nurse's Note dated 07/09/12 at 11:00 PM revealed at 4:25 PM the nurse was called to Resident #103's room. 156. Upon entering the room the nurse observed the resident lying on the floor near her dresser, 157. The nurse immediately assessed the resident from head to toe. 158. Range of motion to upper and lower extremities was performed. 159. The nurse observed swelling to the resident's left eye lid and nose. 160. There was also bruising to both areas. 161. The nurse and the certified nursing assistant transferred the resident to bed without difficulty. -.162, The nurse contacted the physician and received an order to send the resident to the hospital for evaluation. ‘ 163. Neurological checks were started, 164. Per the nurse's note the resident returned to the facility at 09:30 PM that evening with a diagnosis of a fracture to the nostril. 165. On 08/08/12 at 4:26 PM the Acting Regional Dixector of Clinical Services and the Nursing Home Administrator confirmed there was no documentation that Resident #103 was being monitored for safety or that the safety belt was in place at the time of the 07/09/ 12 fall or that there was an ‘order to discontinue the resident's safety belt, 166. On 08/08/12 at 5:17 PM a telephone interview with the Licensed Practical Nurse (LPN #7) revealed she was just beginning her shift when Resident #103's daughter arrived at the - . facility. 167. Per LPN #7 the daughter informed the staff that her mother was on the floor. 168. LPN #7 revealed the resident was climbing out the bed and that was why the Certified Nursing Assistant (CNA) put the resident in the wheelchair. 169, LPN #7 confirmed no restraints were in place at the time of the resident's fall. 170. On 08/08/12 at 5:32 PM teview of the 15-Day Adverse Report dated 07/25/12 indicated the fall and subsequent nose fracture for Resident 4103 was a non-adverse event. 171, Review of the report revealed the outcome of the event was a fracture or dislocation of bones or joints. 172. The circumstances of the event were Resident #103 had gotten out of bed and had 7 ‘her wheelchair brakes applied and call light within reach. 173. She was found fen minutes later on the floor and had not indicated through cali light or other means that she wanted to go back to bed. | 174. The analysis and corrective action included Resident #103 had no recent falls and had been transferred safely with the protocols the facility was using and so the staff had not been able to predict that this would happen. 175. Resident #103 was sent to the hospital for evaluation and treatment and returned shortly with a fractured nose and some bruising to the face. | 176. The corrective action included the initiation of a safety belt for her safety in addition to the other protocols in place. 177. Continued review revealed another 15-Day Adverse Report dated 08/01/12. 178. This report revealed the date of the incident was 07/09/12-at 4:25 PM. 179. After a complete investigation, the risk manger determined that the incident did qualify as an adverse incident. . 180. Circumstances of the event revealed that on 07/09/12 Resident #103 were provided care by her assigned CNA, 181. She was immediately placed in her wheelchair. 182. Shortly after the CNA exited the room, Resident #103 was noted lying on the . floor. | 183. She was noted with bruising to the face and nose. 184. Her attending physician was notified and orders were received to send patient to the emergency room for further evaluation. 185, Resident .#103 was transferred back to the center with a diagnosis of nasal 18 fracture, © 186. The analysis (apparent cause) of this incident was upon reviewing the medica] record for Resident #103, she was noted to have orders for a safety belt. 187. Prior to the fail, Resident #103 did not have the safety belt in place, 188. If the safety belt had been in place it could have possibly prevented the fall and ov/injury. | 189, The deficiency was isolated. . 190, Under Florida law, 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 xeceiving 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. § 400.023(8)(a), Fla. Stat. (2012). 191. Under Florida law, a class | deficiency is subject to a civil penalty of $10,000 for - an isolated deficiency, 12,500 for a pattemed 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 T or class II deficiencies during the last licensure inspection or any inspection or complaint investigation since the last licensure inspection. A fine ist be levied notwithstanding the correction of the deficiency, § 400.023(8)(a), Fla. Stat. (2012). Under Florida Jaw, cach day of violation constitutes a separate violation and is subject to a separate fine. § 408.813(1), Fla. Stat. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to irapose an administrative fine of $10,000.00 against the Respondent. 19 COUNT It Failure to Protect Against and Report Abuse and/or Neglect 192. Under Florida law, all licensees of nursing home facilities shall adopt and make ; public a statement of ‘the tights and responsibilities of the sesidents of such facilities and shall treat such residents in accordance with the provisions of that statement, § 400.022(1), Fla. Stat, - 2019), The statement shall assure each resident ... The right to be treated courteously, fairly, and with the fullest measure of dignity and to receive a written statement and an oral explanation of the services provided by the licensee, including those required to be offered on an as-needed basis, The tight to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints ‘authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case. of an emergency, restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety. § 400,022(1)(n)-(0), Fla. Stat. (2012). "193. Under Florida law, “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.” § 415.102(1), Fla. Stat. (2012). 194. Under Florida law, “Neglect” means “the failure or omission on the part of the caregiver or vulnerable adult to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including, but ‘not limited to, food, 20 clothing, medicine, shelter, supervision, and medical services, which a prudent person would consider essential for the well-being of a vulnerable adult.” § 415.102(16), Fla. Stat. (2012), The term “neglect” also means the failure of a caregiver or vulnerable adult to make a reasonable effort-to protect a vulnerable adult from abuse, neglect, or exploitation by others, “Neglect” js repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological iojury or a substantial risk of death. § 415.102(16), Pla, Stat. (2012), 195. Under Florida law, any person, including, but not limited to, any: ... Nursing home staff; assisted living facility staff adult day care center staff; adult family-care home staff: social worker; or other professional adult care, residential, or institutional staff, ... who knows, or has reasonable cause to suspect, that a vulnerable adult has been or is being abused, neglected, or exploited shall immediately report such knowledge ot suspicion to the central abuse hotline. § 415.1034(1)(a)4, Fla, Stat. (2012). To the extent possible, a report made pursuant to paragraph (a) must contain, but need not be limited to, the following information: 1. Name, age, race, sex, physical description, and location of each victim ‘alleged to have been abused, neglected, or . exploited. 2, Names, addresses, and telephone numbers of the victim’s family members. 3. Name, address, and telephone number of each alleged perpetrator, 4, Name, address, and telephone number of the caregiver of the victim, if different from the alleged perpetrator. 5, Name, address, and telephone number of the person reporting the alleged abuse, neglect, or exploitation. 6. Description of the physical or psychological injuries sustained. 1. Actions taken by the xeporter, if any, such as notification of the criminal justice agency. 8. Any other information available to the reporting person which may establish the cause of abuse, neglect, or exploitation that occurred or is occurring. § 415.1034(1)(b), Fla. Stat, (2012). 21 196, The Agency conducted a survey of the Respondent and its Facility on or about August 7-11, 2012. 197. Based on observation, family and staff interviews, and clinical and facility records review, the Facility failed to implement their written policies and procedures related to resident abuse for J (Resident #103) of 4 sampled residents. It was discovered that Resident #103 had a bruise of unknown origin on her genitalia. The Facility failed to implement its abuse prohibition policies and procedures for reporting this discovery to immediately notify the Clinical Nurse in charge, or Director, Director of Clinical Services or Executive Director according to the facility policy, The Facility also failed to implement its abuse prohibition policies and procedures to conduct a thorough investigation, which should have included the IDON/Abuse Coordinator performing or documenting a thorough nursing assessment promptly and requesting a medical examination. to determine if there was trauma or sexual assault, ) The failure of the Facility to implement its abuse prohibition policies and procedure for reporting and investigation for a potential physical or sexual assault could delay medical/psychological treatment for the resident, as well as put other residents at risk, and interfere with the collection of forensic evidence. 198. An observation of Resident #103 on, 08/09/ 12 at 2:20 PM revealed the resident sleeping and her daughter was at the bedside. 199, Per the daughter, she recently found bruising on her mother's vagina, 200. She revealed the Unit Manager informed her that the bruising was a result of the incontinence brief her mother was wearing, 201, A clinical record review for Resident #103 revealed she was admitted to the facility on 01/21/12 with a readmission date of 01/30/12. 202. The admission diagnosis included pneumonia, diabetes type 2 without 22 complications, senile dementia, hypertension, edema, aphasia and Gastrostomy (G-tube). : 203. A review of the Admission Data Collection Form dated 01/30/12 revealed that the resident had a language barrier, and staff was unable to orient the resident because she spoke - Arabic. ) 204. A review of the Admission Minimum Data Set (MDS) Assessment with an Assesement Reference Date (ARD) of 02/09/1 2, Section B, revealed the resident had no speech, was zarely or never understood by others and was rarely or never able to make herseif understood. | 205, It also revealed the resident was totally dependent for bed mobility, transfers, and locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. 206. A review of the Quarterly MDS Assessment with an ARD of 04/27/12 revealed Resident #103 had no speech, was rarely or never understood by others and was rarely or never able to make herself understood. 207, _ It also revealed the resident was totally dependent for bed mobility, transfers, and ‘locomotion on and off the unit, dressing, eating, toilet use and personal hygiene. 208. A review of the physician's order's for Resident #103 revealed an order dated 07/29/12 to monitor a bruise to vagina every shift until healed. 209. A review of the Nurses Note dated 07/27/12 for Resident #103 (untimed) revealed the resident's daughter brought to the nurse's attention a bruise on her mother's peri- area. 210. The note also revealed that the resident complained of pain to the right abdomen when coughing or pressing the right lower quadrant of het abdomen. 211, A Nurses Note dated 07/28/12 (untimed) for Resident #103 revealed the nurse continued to observe bruising to the outer aspect of the labia majora. 23 "212. Review of the Physician/Nurse Practitioner/Physician Assistant Communication, and Progress Note for New Symptoms, Signs and other changes in condition (SBAR) forms dated 07/28/12, 07/29/12 and 07/30/12 revealed evidence that the daughter had reported on 07/27/12 the bruise on the resident genitalia. 213. The instructions on the form indicated that the form should be completed before ; contacting the physician. 214. A review of the form revealed that "S" was the Situation, "B" was ‘the Background, "A" was the Assessment or Appearance, and "R" was the request. 215. The section on the forms to document the date, time and name of the doctor, nurse practitioner or physician's assistant was blank. 216. On 08/09/12 at 2:52 PM an interview with the GNR Unit Manager (UM), Nursing Home Administrator/Risk Manager (NHA/RM), and IDON/Abuse Coordinator revealed that the GNR UM and IDON/AC examined the resident on 07/30/12. . 207. _The IDON revealed she completed the physical assessment of the bruise on Resident #103's vagina on 07/30/12 after the morning meeting, 218. The [DON indicated the resident had a linear bruise consistent with the rubber of an incontinence brief. 219. . She revealed she discussed the findings with the physician. 220, She revealed she did not believe the resident was assessed by the physician, but an order was obtaiied to monitor the area. Ze On 08/10/12 at 11:15 AM, a telephone interview with Nurse #60 revealed that on 07/27/11 on the 3-11 pm shift, Resident #103's daughter approached her while she was at the medication cart and requested something for pain for her mother. 24 222. She revealed she went down to evaluate the resident as the daughter had mentioned that she had observed a bruise to her mother's vagina. 223, The nurse revealed the she observed the resident's vaginal area and determined there was a bruise to the labia minora (lip of the vagina) that was bluish-purplish in color, and’ about in to2 inches long. | 24. The nurse revealed that she did not know what happened to the resident including what caused the bruise or when the resident sustained the bruise, 225. The nurse revealed that she did not see any concems with the way the brief was applied. 226. The nurse revealed that she called the physician and did not receive a call back. 227.. She revealed she reported off to the oncoming nurse so that when the physician did called back they would know the reason for the call, 228, ‘The nurse stated that she documented in the chart and also completed a bruise report and documented the incident on the 24 hour report. _ . 229, She revealed she did not inform management about the bruise to the resident's vagina, because there was no management available. 230. A review of the Comprehensive 24- Hour Report (Quality Assurance) dated 07/27/12 revealed there was documentation Resident #103's family had concerns regarding a bruise on the resident and a report form was filled out. 231. There was no documentation an attempt had been made to notify the physician. 232. On 08/10/12 at 12:58 PM a telephone interview with the Advanced Registered . Nurse Practitioner (AR'NP) revealed that he was familiar with Resident #103, but had not physically evaluated the resident in about two months. 25 233. He was advised there was a telephone order indicating the nurse spoke to him about a vaginal bruise to the resident's vagina on 07/29/12. ) 234. He revealed that he did not remember receiving a phone call from the Facility regarding an incident with the resident having vaginal bruising. 235. He revealed that was not a typical phone call he would receive and something like that would stand out to him. 236. On 08/10/12 at 1:14 PM a telephone interview with certified nursing assistant (CNA) #61 revealed she was the aide caring for the resident when the daughter noted the bruise to her mother's vagina. 4 , 237. She revealed she did not know how the bruise occured or when it occurred and she teferred the resident's daughter io the nurse. 238. She also xevealed she observed the bruise on the resident's vagina. 239. During.an interview with NHA/RM on 08/10/12 at 1:25 PM, it was revealed that _ the incident occurred before he was employed at the facility, 240. He revealed he became aware of the incident when he went through the incident reports, . ‘241 7 He revealed he trusted the DON's decision about notifying the physician. 242. He also revealed the protocol for investigation of bruising would depend on the situation and that he was not always notified; it depended on the type of bruising. 243, If the issue had the making of an adverse incident then he would be notified. 244, He revealed the incident reports are reviewed at the morning meetings and if there was poteritial abuse he would be notified and it would be investigated. 245. Per the NHA/RM the IDON was convinced it was the brief that was applied 26 inappropriately and that was what cansed the bruising. 246. There were no statements that indicated abuse. 247. He also revealed that he would have expected something like vaginal bruising to be reported to the IDON at the time it was found. 248, An interview with Physician #1 on 08/10/12 at 2:06 PM revealed he was not notified that Resident #103 had vaginal bruising. 249, He revealed his ARNP was notified on 07/29/12. He revealed that he had not | examined the resident until today. 250. His examination revealed the resident had minimal erythema (redness) on the tight groin, no excoriation or drainage. . ) -,251, There was no evidence of trauma. 252. He indicated the erythema appeared to be due to a brief. 253, He revealed the resident had severe dementia, was in the facility for end of life care because of a brain tumor and was totally dependent on staff for care. 254. An interview ‘with Resident #103's Attending Physician and the Director of Medical Services on 08/11/12 at 9:10 AM revealed he was not made aware that Resident #130 had vaginal bruising on 07/27/12, 255. A review of the Resident Abuse Policy and Procedure dated 01/07, revised O1/ 10 . revealed that the policy section included, but was not limited to the following: Itis in the nature and dignity of each resident at Consulate Health Care that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. 256. The Procedure section included, but was not limited to the following: ‘21 VI. Identification. All reported events (bruises, skin tears, falls, inappropriate or abusive behaviors) will be investigated by the Clinical Director of Services. Pattems or trends will be identified that might constitute abuse. This information will be forwarded to the Executive Director, who will serve as the facility's Abuse Coordinator, and an abuse investigation will be conducted in the absence of the Executive Director, the Director of Clinical Services will serve as Abuse Coordinator. VIL Procedure for Reporting Abuse A. All incidents of resident abuse are to be reported immediately to the Clinical Nurse in Charge, Director of Clinical Services, or the Executive Director. Once reported to one of those three officials, the prescribed forms are to be completed and delivered to the Abuse Coordinator or his/her designee for an investigation. VII. The Abuse Coordinator of Consulate Health Care will endeavor to protect the sights of residents and employees, The administrator recognizes that preliminary reports of abuse can sometimes be clouded by biases and other factors that are relevant and need to be explored during a full investigation in order to obtain a clear picture of what actually happened. Thus, while the Administration reserves, the right to suspend pending an investigation, such suspension is not be deemed as an assessment of guilt, IX. Investigation of Abuse. A. The Abuse Coordinator or his/her designee shall investigate all reports of suspected abuse. A Social Service representative shall be present in the role of resident advocate during any questioning of or interviewing of residents. B, Investigations will be accomplished in the following manner. 1. Preliminary investigation: .... c. The Clinical Nurse in charge or Director of Clinical Services shall perform and document a thorough nursing assessment, and notify the attending physician. d. An incident report shall be filed by the . individual in charge who received the report in conjunction with the person who reported the abuse. “This report should be filed as soon as possible in order to provide the most accurate information in a timely fashion. 2. Investigation a. The Abuse/Coordinator and/or Director of Clinical Services shall take statements from the victim, the suspect(s) and all possible witnesses including all other employees in the vicinity of the alleged abuse. He/she shall also secure all physical evidence. Upon completion of the investigation, a detailed report shall be prepared. b. Any suspect (s), once he/she has (have) been identified will be suspended pending the investigation. 3. Review of Report: a. Once completed, the investigation's report ‘shall be reviewed by the Director of Clinical Services, the Abuse Coordinator, and one other Administrative staff member. 4, Discipline: .... c. The Abuse Coordinator of Consulate Healthcare will refer any or all incidents and reports of abuse to the appropriate state agencies. 28 . 257, The deficiency was isolated. 258. Under Florida law, a class I deficiency is a deficiency that the Agency determines presents a situation in- which immediate corrective action is necessaty 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 1 violation shall be abated or eliminated immediately, unless a fixed period of time, as determined by the agency, is required for correction. § 400.023(8)(a), Fla. Stat. (2012). 259, Under-Florida law, 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 Tor 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. § 400.023(8)(a), Fla. Stat. (2012). Under Florida law, each day of violation constitutes a separate violation and is subject to a separate fine. § 408.813(1), Fla, Stat. (2012). WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, respectfully intends to impose an administrative fine of $10,000.00 against the Respondent. COUNT IV Assignment of Conditional Licensure Status 260. The Agency re-alleges and incorporates by reference Counts I through TIL. 261. The Agency is authorized to assign a conditional licensure status to skilled nursing facilities pursuant to Section 400.23(7), Florida Statutes (2012). 262. Due to the presence of one class I deficiency or one class II deficiency, the Respondent was not in substantial compliance at the time of the survey with criteria established 29 a ¥ undér Chapter 400, Part II, Florida Statutes (2012), or the rules adopted by the Agency, 263, The Agency assigned the Respondent conditional licensure status with an action | effective date of August 1 1 2012. . WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, . respectfully intends to impose conditional licensure status against the Respondent. COUNTY Six-Month Survey Cycle 264. The Agency re-alleges and incorporates by reference the allegations in Count I. 265. The Respondent was cited for one Class | deficiency and therefore is subject to a six month survey cycle for a period of two years and a survey cycle fine of $6,000.00 pursuant to Section 400.19(3), Florida Statutes (2012). . WHEREFORE, the Petitioner, State of Florida, Agency for Health Care Administration, - _ respectfully intends to impose a six month survey cycle for a period of two years and a survey cycle fine of $6,000.00 against the Respondent. Respectfully submitted on this 31st day of August, 2012. Florida Bar No. 7934: Agency for Health Gare Administration Office of the General.ounsel 2727 Mahan Drive, Mail Stop #3 Tallahassee, Florida 32308 Telephone: (850) 412-3640 Facsimile: (850) 921-0158 30 NOTICE " The Respondent has the right to request a hearing to be conducted in accordance with 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 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 . [HEREBY CERTIFY that a trie and correct copy of the Administrative Complaint and Election of Rights-form were served to the below named persons by the method designated on . Carlton Enfinger II, Sexsor Attorney Florida Bar No. 793450 this 31st day of August, 2012. Office of the General, 2727 Mahan Drive, Ma Tallahassee, Florida 32308 Telephone: (850) 412-3640 Facsimile: (850) 921-0158 Facility Administrator Robert Dickson, Field Office Manager Consulate Health Care of Jacksonville Jacksonville Field Office 4101 Southpoint Drive East Agency for Health Care Administration Jacksonville, Florida 32216 (Electronic Mail) (Certified Mail — 7008 1300 0000 6174 1978) 31 COMPLETI: THIS SECTION ON DELIVERY CERTIFIED W iia’ SE cs) i. (Domestic Mail mi No| ™ Complete ve loreneeancts Ao ‘coniptete ry fe i Item 4 if Reatrloted Delivery is ‘desired. m Print your name and address on the reverse ot - 80 that wo oan return the card to you. wt . ® Attach this card to the back of: in mailplace, a or on the front if space permits, | “. i—& mers ners ‘acility Adminis 1. Antlole Addrossed to: — OD, Is delWvery address al ferent from tem. Cry = none Consulate Healt 4 ” IF YES, enter delivery address below: = ] No 5 ly 101 Southpoint Gesticoc acksonville, Flo} - _ Facility Administrator 5] . : Constifate Health Care of Jacksonville m : ry al Poe co "4101 Southpoint Drive East See wy [S00 —— 5 Jacksonville, Florida 32216 Certified Mall [2] Express Mall a aie Lot} O Registered feturn Recefpt for Merchandise ca Brash A We Cineured Mall £1 0,00. Cli Bata ABET ee 4, Restricted Delivery? (Extra Foo) t1-Yes 2008 4300 oo00 174 Live i MA tte eerie ee ten enema gene [pa yap -rontre ar aee tr ratrttanapuntranronn/anannnnstesussnstnsesnnninsnsnaainineneoreriioninneren| ? PS Form 3811, February 2004 Domestic Return Racelpt 402698-02-M-1640,

Docket for Case No: 12-003285

Orders for Case No: 12-003285