The Issue Whether Respondent committed the violations alleged in the Administrative Complaints and, if so, what penalty should be imposed.
Findings Of Fact Stipulated facts AHCA is the agency responsible for the licensing and regulation of skilled nursing facilities in Florida pursuant to Chapter 400, Part II, Florida Statutes, and Chapter 59A-4, Florida Administrative Code. At all times material hereto, Avante was licensed by Petitioner as a skilled nursing facility. Avante operates a 116-bed nursing home located in Leesburg, Florida. On or about March 28, 2002, AHCA conducted a complaint investigation at Avante. Based on AHCA's findings during the March 28, 2002, complaint investigation, federal tag F281(D) was cited against Avante. On or about May 13, 2002, AHCA conducted a survey at Avante. Based on AHCA's findings during the May 13, 2002, survey, federal tag F281(D) was cited against Avante. Resident E.S. was admitted to Avante on March 11, 2002, with diagnoses including e. coli sepsis, anemia, and schizophrenia with an order for serum albumin levels to be performed "now and yearly." Resident E.S.'s resident chart failed to reflect that a serum albumin test had been performed for Resident E.S. at any time from the date of his admission on March 11, 2002, until March 28, 2002. Avante failed to follow the orders of Resident E.S.'s physician due to its failure to perform a serum albumin test on Resident E.S. at any time between March 11, 2002, and March 28, 2002. Resident R.L. was admitted to Respondent's facility on May 6, 2002 with diagnoses including gastrointestinal hemorrhage, congestive heart failure, coronary artery disease, A-fib, pneumonia, diverticulitis, gout, fracture of right arm, and cancer of the prostate. Resident R.L.'s resident chart reflects that Resident R.L. was neither offered or administered Tylenol by Avante's staff at any time between May 9, 2002, and May 13, 2002. Facts Based Upon the Evidence of Record The correction date given to Respondent for the deficiency cited, Tag F281(D), as a result of the March 28, 2002, complaint investigation was April 28, 2002. Respondent does not dispute the deficiency cited by AHCA as a result of the March 28, 2002, complaint investigation. Thus, facts and circumstances surrounding the May 13, 2002, survey visit to Avante is the source of this dispute. The purpose of the May 13, 2002 survey visit to Avante by AHCA was for annual certification or licensure. In an annual license survey, a group of surveyors goes to a facility to determine if the facility is in compliance with state and federal requirements and regulations. Part of the process is to tour the facility, meet residents, record reviews, and talk to families and friends of the residents. During the licensure visit on May 13, 2002, the records of 21 residents were reviewed. Stephen Burgin is a registered nurse and is employed by AHCA as a registered nurse specialist. He has been employed by AHCA for three years and has been licensed as a nurse for six years. He also has experience working in a hospital ER staging unit and in a hospital cardiology unit. Nurse Burgin has never worked in a nursing home. Nurse Burgin conducted the complaint investigation on March 28, 2002, and was team leader for the licensure survey visit on May 13, 2002, at Avante. He was accompanied on the May 13, 2002, visit by Selena Beckett, who is employed by AHCA as a social worker. Both Nurse Burgin and Ms. Beckett are Surveyor Minimum Qualification Test (SMQT) certified. During the course of the May 13, 2002, licensure survey visit, Ms. Beckett interviewed Resident R.L. As a result of this interview, Ms. Beckett examined Resident R.L.'s medication administration record (MAR) to determine whether he was receiving pain medication for his injured left elbow. As a result of reviewing Resident R.L.'s record, Ms. Beckett became aware of a fax cover sheet which related to Resident R.L. The fax cover sheet was dated May 8, 2002, from Nancy Starke, who is a registered nurse employed by Avante as a staff nurse, to Dr. Sarmiento, Resident R.L.'s attending physician. The box labeled "Please comment" was checked and the following was hand written in the section entitled "comments": "Pt refused Augmentin 500 mg BID today states it causes him to have hallucinations would like tyl for pain L elbow." According to Nurse Starke, the fax to Dr. Sarmiento addressed two concerns: Resident R.L.'s refusal to take Augmentin and a request for Tylenol for pain for Resident R.L.'s left elbow. She faxed the cover sheet to Dr. Sarmiento during the 3:00 p.m. to 11:00 p.m. shift on May 8, 2002. Despite her fax to Dr. Sarmiento, which mentioned pain in R.L.'s left elbow, her daily nurse notes for May 8, 2002, reflect that Resident R.L. was alert, easygoing, and happy. He was verbal on that day meaning that he was able to make his needs known to her. Her daily nurse notes for May 8, 2002 contain the notation: "Pt refused augmentin today. Dr. Sarmiento faxed." According to Nurse Starke, she personally observed Resident R.L. and did not observe any expression of pain on May 8, 2002, nor did Resident R.L. request pain medication after she sent the fax to Dr. Sarmiento. The fax cover sheet also contained the hand written notation: "Document refused by PT. OK 5/9/02" with initials which was recognized by nurses at Avante as that of Dr. Sarmiento. The fax sheet has a transmission line which indicates that it was faxed back to Avante the evening of May 9, 2002. Nurse Starke also provided care to Resident R.L. on May 11, 2002. According to Nurse Starke, Resident R.L. did not complain of pain on May 11, 2002. Theresa Miller is a registered nurse employed by Avante as a staff nurse. Nurse Miller provided care to Resident R.L. on May 9 and 10, 2002, during the 7:00 a.m. to 3:00 p.m. shift. Nurse Miller's nurses notes for May 9 and 10, 2002, reflect that she observed Resident R.L. to be alert, easygoing, and happy. Her notes also reflect that Resident R.L. was verbal on those dates, meaning that he was able to tell her if he needed anything. She did not observe Resident R.L. to have any expression of pain on those dates, nor did Resident R.L. express to her that he was in any pain. Vicki Cannon is a licensed practical nurse employed by Avante as a staff nurse. Nurse Cannon has been a licensed practical nurse and has worked in nursing homes since 1998. Nurse Cannon provided care to Resident R.L. on May 11 and 12, 2002, on the 7:00 a.m. to 3:00 p.m. shift. Her nurse's notes for May 11, 2002 reflect that Resident R.L. was sullen but alert and verbal. Resident R.L. had blood in his urine and some discomfort. Nurse Cannon contacted Dr. Sarmiento by telephone on May 11, 2002, to inform him of Resident R.L.'s symptoms that day. Nurse Cannon noted on Resident R.L.'s physician order sheet that she received a telephone order from Dr. Sarmiento to give Resident R.L. Ultram PRN and Levaquin, discontinue Augmentin, order BMP and CBC blood work, and a urology consult. Ultram is an anti-inflammatory and a pain medication. Ultram is stronger than Tylenol. The notation "PRN" means as requested by the patient for pain. Levaquin is an antibiotic. Nurse Cannon faxed the order to the pharmacy at Leesburg Regional Medical Center. By the time Nurse Cannon left Avante for the day on May 11, 2002, the Ultram had not arrived from the pharmacy. On May 12, 2002, Resident R.L. had edema of the legs and blood in his urine. Nurse Cannon notified Dr. Sarmiento of Resident R.L.'s symptoms. Resident R.L. was sent to the emergency room for evaluation based on Dr. Sarmiento's orders. Additionally, Nurse Cannon called the pharmacy on May 12, 2002, to inquire about the Ultram as it had not yet arrived at the facility. Resident R.L. returned to Avante the evening of May 12, 2002. Alice Markham is a registered nurse and is the Director of Nursing at Avante. She has been a nurse for more than 20 years and has been employed at Avante for a little over two years. She also has worked in acute care at a hospital. Nurse Markham is familiar with Resident R.L. She described Resident R.L. as alert until the period of time before he went to the hospital on May 12, 2002. She was not aware of any expressions of pain by Resident R.L. between May 9, 2002 until he went to the hospital on May 12, 2002. Nurse Markham meets frequently with her nursing staff regarding the facility's residents. During the licensure survey, Nurse Markham became aware of Ms. Beckett's concerns regarding Resident R.L. and whether he had received Tylenol. She called Dr. Sarmiento to request an order for Tylenol for R.L. The physician order sheet for R.L. contains a notation for a telephone order for Tylenol "PRN" on May 14, 2002, for joint pain and the notation, "try Tylenol before Ultram." The medical administration record for R.L. indicates that Resident R.L. received Ultram on May 13 and and began receiving Tylenol on May 15, 2002. AHCA 's charge of failure to meet professional standards of quality by failing to properly follow and implement physician orders is based on the "OK" notation by Dr. Sarmiento on the above-described fax and what AHCA perceives to be Avante's failure to follow and implement that "order" for Tylenol for Resident R.L. AHCA nurse and surveyor Burgin acknowledged that the "OK" on the fax cover sheet was not an order as it did not specify dosage or frequency. He also acknowledged that the nursing home could not administer Tylenol based on Dr. Sarmiento's "OK" on the fax cover sheet, that it would not be appropriate to forward the "OK" to the pharmacy, that it should not have been placed on the resident's medication administration record, and that it should not have been administered to the resident. However, Nurse Burgin is of the opinion that the standard practice of nursing is to clarify such an "order" and once clarified, administer the medication as ordered. He was of the opinion that Avante should have clarified Dr. Sarmiento's "OK" for Tylenol on May 9, 2002, rather than on May 14, 2002. Nurse Burgin also was of the opinion that it should have been reflected on the resident's medication administration record and treatment record or TAR. In Nurse Markham's opinion, "OK" from Dr. Sarmiento on the fax cover sheet does not constitute a physician's order for medication as it does not contain dosage or frequency of administration. Nurse Markham is also of the opinion that it should not have been forwarded to the pharmacy, transcribed to the medication administration record, or transcribed on the treatment administration record. According to Nurse Markham, doctor's orders are not recorded on the treatment administration record of a resident. Nurse Markham is of the opinion that the nursing staff at Avante did not deviate from the community standard for nursing in their care of Resident R.L. from May 8, 2002 to May 14, 2002. Nurse Cannon also is of the opinion that the "OK" by Dr. Sarmiento does not constitute a physician's order for medication. The Administrative Complaints cited Avante for failure to meet professional standards of quality by failing to properly follow and implement a physician's order. Having considered the opinions of Nurses Burgin, Markham, and Cannon, it is clear that the "OK" notation of Dr. Sarmiento on the fax cover sheet did not constitute a physician's order. Without Dr. Sarmiento's testimony, it is not entirely clear from a review of the fax cover sheet that the "OK" relates to the reference to Tylenol or the reference to Resident R.L.'s refusal of Augmentin. Accordingly, Avante did not fail to follow a physician's order in May 2002. As to AHCA's assertion that Avante failed to meet professional standards by not clarifying the "OK" from Dr. Sarmiento, this constitutes a different reason or ground than stated in the Administrative Complaints. Failure to clarify an order is not the equivalent of failure to follow an order. There is insufficient nexus between the deficiency cited on March 28, 2002 and the deficiency cited on May 13, 2002. Accordingly, Avante did not fail to correct a Class III deficiency within the time established by the agency or commit a repeat Class III violation. Moreover, the evidence shows that the nursing staff responded to the needs of Resident R.L. Resident R.L. expressed pain in his left elbow to Nurse Starke on May 8, 2002. Resident R.L. was alert and could make his needs known. He did not express pain or a need for pain medication to Nurse Miller on May 9 or 10, 2002 or to Nurse Cannon on May 11 or 12, 2002. Rather, Nurse Cannon noted a change in his condition, notified Dr. Sarmiento which resulted in Resident R.L. being sent to the emergency room. Resident R.L. returned to Avante the evening of May 12, 2002, and received Ultram for pain on May 13, 2002, when the medication reached Avante from the pharmacy. The evidence presented does not establish that Avante deviated from the community standard for nursing in its actions surrounding the "OK" from Dr. Sarmiento. In weighing the respective opinions of Nurses Burgin and Markham in relation to whether the community standard for nursing was met by the actions of Respondent, Nurse Markham's opinion is more persuasive.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is RECOMMENDED: That the Agency for Health Care Administration enter a final order dismissing the Administrative Complaints issued against Respondent, Avante at Leesburg. DONE AND ENTERED this 13th day of December, 2002, in Tallahassee, Leon County, Florida. BARBARA J. STAROS Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 13th day of December, 2002. COPIES FURNISHED: Jodi C. Page, Esquire Agency for Health Care Administration 2727 Mahan Drive Mail Station 3 Tallahassee, Florida 32308 Karen L. Goldsmith, Esquire Jonathan S. Grout, Esquire Goldsmith, Grout & Lewis 2180 Park Avenue North, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3, Suite 3431 Tallahassee, Florida 32308-5403 Valinda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3, Suite 3431 Tallahassee, Florida 32308-5403
The Issue Whether the Respondent committed the offenses set forth in the Administrative Complaint and , if so, what disciplinary action should be taken.
Findings Of Fact Respondent, Dalia V. Gonzalez, was at all times material hereto, licensed as a registered nurse in the State of Florida, having been issued license number RN 88664-2. On August 16, 1988, Respondent was employed as a charge nurse for the skilled unit portion of a floor at Coral Gables Convalescent Center. The remaining portion of the floor was a long term intermediate care unit with a licensed practical nurse, Ms. Jane Reilly Perkins, serving as charge nurse for said unit. During the change of shifts and between 6:30 a.m. and 7:00 a.m. on August 16, 1988, a threatening argument, over the number of personnel assigned to each portion of the floor, arose between Respondent and Ms. Reilly who was accompanied by another licensed practical nurse. Ms. Reilly is a female of physically imposing stature; therefore, Respondent, reasonably fearing her safety, locked herself in her office and called her supervisor to ask for assistance. Respondent remained locked in her office for approximately two hours awaiting the arrival of her supervisor. During this time, Respondent was in constant contact with the other medical personnel on her floor. Although she was the only registered nurse present, her personal service as a registered nurse was not required at the time nor was she prohibited from giving it had the necessity arisen. When Respondent's supervisor, a registered nurse, arrived, they discussed the situation with Ms. Reilly. During this discussion, Respondent gave her first notice of intent to leave her position. After being informed that if she left, she would lose her position at Coral Gables Convalescent Center, Respondent handed her keys to her supervisor and left the facility not completing her assigned shift. While Respondent was available to her patients, although locked in her office during her shift, she did leave her nursing assignment without notifying her supervisor of her intent to leave within sufficient time to allow substitute arrangements to be made. Respondent's notice was improper Consequently, Respondent acted with unprofessional conduct.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED the a final order be entered reprimanding Petitioner. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 19 day of June 1989. JANE C. HAYMAN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division Administrative Hearings this 19 day of June 1989. APPENDIX TO RECOMMENDED ORDER CASE NO. 89-325 Petitioner's proposed findings of fact are addressed as follows: Addressed in paragraph 1. Addressed in paragraph 1. Addressed in paragraph 2. Addressed in paragraph 2. Addressed in paragraph 3. Not necessary to result reached. Addressed in paragraph 2. Addressed in paragraph 3. Addressed in paragraph 3. To the extent supported by competent proof, addressed in paragraph 3. Addressed in paragraph 4. Subordinate to the result reached. Subordinate to the result reached. Addressed in paragraph 6. Not supported by competent and substantial evidence. Addressed in paragraph 5. Not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Addressed in paragraph 6. Addressed in paragraph 6. Addressed in paragraph 5. Not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Not supported by competent and substantial evidence. Addressed in paragraph 6. COPIES FURNISHED: Lisa M. Basset, Esquire Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0729 Santiago Pellegrini, Esquire 1570 Northwest Fourteenth Street Miami, Florida 33125 Judie Ritter Executive Director Board of Nursing 504 Daniel Building 111 East Coastline Drive Jacksonville, Florida 32201 Kenneth E. Easley General Counsel Department of Professional Regulation 1940 North Monroe Street Suite 60 Tallahassee, Florida 32399-0729 =================================================================
Findings Of Fact Respondent is a skilled nursing home facility located in Blountstown, Florida, and is licensed by HRS. During a routine survey (inspection) of Apalachicola Valley Nursing Center on January 7-8, 1980, a staffing analysis revealed that for the three weeks prior to the survey, Respondent was short one licensed nurse on the night shift (11:00 p.m. to 7:00 a.m.) for this 21-day period. During the entire period here involved, the adjusted average census of the Respondent was over 60 patients. At the time of this survey, Petitioner's policy was not to cite staff shortages as deficiencies on HRS Form 553D unless they affected patient care or there was a deficiency in patient care to which a staff shortage could relate. At all times here relevant, Mrs. Margaret Z. Brock was Administrator and part-owner of the Respondent. Following the January 7-8, 1980 survey, the results were discussed with Mrs. Brock. The head of the survey team advised Mrs. Brock of HRS' policy on staff shortages which did not affect patient care. As a result of unfavorable publicity regarding HRS' laxness in enforcing regulations involving medical facilities, by memorandum dated January 10, 1980 (Exhibit 2), HRS changed the policy on staff shortages which did not affect patient care. This change directed all staff shortages to be noted on the inspection report (Form 553D), which would thereby require action by the facility to correct. It further provided that all such shortages be corrected within 72 hours and if not corrected within the time specified, administrative action against the facility would be taken. By letter dated January 15, 1980, Mrs. Brock was forwarded the survey report containing the deficiency relating to the shortage of one LPN on the night shift during the three-week period prior to the survey. A follow-up visit was made to the Respondent on February 21, 1980, at which time it was noted that the LPN shortage on the night shift remained uncorrected. By letter dated February 27, 1980 (Exhibit 3), Mrs. Brock was advised of this finding and the accompanying Form 553D stated that the deficiency was referred for administrative action. This resulted in the Administrative Complaint in Docket No. 80-1443. A second follow-up visit was made on March 25, 1980, at which time it was noted that the LPN shortage on the 11:00 p.m. to 7:00 a.m. shift was still uncorrected. By letter dated April 1, 1980 (Exhibit 4), Mrs. Brock was advised of this finding and the accompanying Form 553D indicates that the deficiency is again being referred for administrative action. This resulted in the Administrative Complaint in Docket No. 80-1444. There is a shortage of nurses, both registered and licensed practical, nationwide, as well as in the panhandle of Florida. This shortage is worse in smaller towns and rural areas than in more metropolitan areas. Respondent is located in a rural area. Respondent has encouraged and assisted potential employees to attend the LPN courses given in nearby technical schools. One of these enrollees is currently working for Respondent. Respondent has advertised in newspapers for additional nursing personnel and has offered bonuses to present employees if they can recruit a nurse to work for Respondent. Other hospitals and nursing homes in the panhandle experience difficulties in hiring the number of nurses they would like to have on their staff. All of those medical facilities, whose representatives testified in these proceedings, have difficulty employing as many nurses as they feel they need. The LPN shortage is worse than the RN shortage. None of these medical facilities, whose representatives testified to the nurse shortage, except Respondent, was unable to meet the minimum staffing requirements of HRS although they sometimes had to shift schedules to meet the prescribed staffing. Respondent has found it more difficult to keep nurses on the 11:00 p.m. to 7:00 a.m. shift than other shifts, particularly if these employees are married or have families. Because of this staffing shortage, on July 18, 1980, a moratorium was placed on Respondent's admitting additional patients. This moratorium was lifted presumably after Respondent met the prescribed staffing requirements by employing a second nurse for the 11:00 p.m. to 7:00 a.m. shift. Failure to meet minimum staffing requirements is considered by Petitioner to constitute a Class III deficiency.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is recommended that the Administrative Complaint in Docket No. 80-1443 be dismissed. It is further recommended that for failure to comply with the minimum staffing requirements after February 21, 1980, Respondent be fined $500.00. DONE and ENTERED this 7th day of November, 1980, at Tallahassee, Florida. K. N. AYERS, Hearing Officer Division of Administrative Hearings Room 101, Collins Building Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 7th day of November, 1980. COPIES FURNISHED: John L. Pearce, Esquire HRS District 2 Legal Office Suite 200-A 2639 North Monroe Street Tallahassee, FL 32303 Stephen D. Milbrath, Esquire Dempsey & Slaughter Suite 610, Eola Office Center 605 E. Robinson Street Orlando, FL 32801
Findings Of Fact At all times material hereto, Petitioner, Joyce Lovasz, was employed as a nurse by Respondent, Boca Raton Community Hospital (Hospital). In 1987, after a medical leave of absence, the Hospital decided not to place Petitioner in the position she held prior to her leave. Petitioner was originally hired by the Respondent in 1970 as a staff nurse. She was promoted to a charge nurse position and then to supervisor of the home health unit. In 1974, she left the Hospital for a position at another hospital. Then, in 1979, Petitioner was asked to return to the Hospital by Tracy Reichert, then, the Director of Nursing Services Administration. Petitioner was selected as head nurse of the I.V. therapy team and began this service on February 12, 1979. In the summer of 1983, Ms. Reichert became aware that there was a significant amount of dissension within the I.V. team and considerable unhappiness on the part of the employees working under Petitioner's supervision with respect to their management by Petitioner. Also, beginning in the summer of 1983, members of the I.V. team met with Terrance Braun, the Hospital's Personnel Director, and discussed their problematic treatment by Petitioner. Their concerns continued, however. Around the same time, some of the I.V. team's members consulted Donna Hearn, who was, then, in charge of the Hospital's Employee Assistance Program. The team members sought Ms. Hearn's counsel because of their concern for Petitioner's well-being, as well as a concern for themselves and their job security. At the meeting with Ms. Hearn, the I.V. team members disclosed behavior of Petitioner which could be characterized as unprofessional. They also talked of Petitioner's favorable actions toward some members of the team. Petitioner's behavior was splitting the team and causing great dissension within it. Some of the Petitioner's actions which caused concern included Petitioner's tape recording of conversations with employees, maintaining a hidden tape recorder in her drawer, taking unexplained absences from the Hospital during scheduled work time, making abrupt scheduling changes, announcing changes in procedures in the middle of doing an I.V. application, and writing different memos to the favored and disfavored factions of the I.V. team concerning the same subject, including constructive memos to the favored team and curt, nonconstructive memos to the disfavored group. The problems persisted, and members of the I.V. team continued to seek counsel from Ms. Hearn throughout the remainder of 1983, and all of 1984 and 1985. Ms. Hearn, who was trained as a counselor, was convinced of the truthfulness of the reports she was receiving from the I.V. team members. As a result of her meetings with the I.V. team, Ms. Hearn discussed the Petitioner's behavior towards I.V. team members with Mr. Braun and Ms. Reichert. Ms. Reichert disclosed to Ms. Hearn that she had concerns about Petitioner's management style and that she would talk to Petitioner. During this period, Ms. Reichert began a dialogue with Petitioner about her management style and problems in supervising the I.V. team. At Ms. Reichert's encouragement, Petitioner visited with Ms. Hearn but was not willing to discuss topics that related to her management of the team. Ms. Reichert had numerous other discussions with Petitioner concerning their difference of opinion on Petitioner's management of her employees and the continuing dissension within the I.V. team. Petitioner grew increasingly critical of Ms. Reichert in front of I.V. team members and was frequently critical of nursing administration in general. In the summer of 1985, Ms. Reichert and Petitioner engaged in a lengthy conversation relating to Petitioner's management of her team. Petitioner asked Reichert if she wanted her to vacate the I.V. head nurse position. Reichert declined on the condition that Petitioner change her management style of supervising the unit. As a result of this meeting, Ms. Reichert decided to assign Ann Capron, Assistant Director of Nursing, to be the immediate supervisor of Petitioner to see if she could influence Petitioner to change her management style and alleviate the problems in the I.V. team. At that point, Ms. Reichert decided to give Ms. Capron six months to work with Petitioner closely and if the problems did not resolve, Ms. Reichert would recommend the termination of Petitioner. The problems continued, however. Ms. Reichert communicated her decision to terminate Petitioner to Normand Guilbault, then Vice President of the Hospital, Mr. Braun and Ms. Capron. However, before action could be taken to implement her decision to terminate Petitioner, Petitioner was diagnosed with ovarian cancer, and in February, 1986, she went on a medical leave of absence which was to last for nearly one year. During her leave of absence, Petitioner was replaced by Trish Hawkins, who had been her unofficial assistant. Under Ms. Hawkins's supervision, the problems which had persisted in the I.V. team for several years disappeared. Ms. Reichert determined that this was due to the absence of Petitioner and to the leadership of Hawkins. Petitioner was eligible for the Hospital's "30, 90, 365 day" leave of absence policy which provided that an employee is guaranteed the same job during the first 30 days of a leave of absence. After the first 30 days and prior to 90 days of a leave of absence, an employee is guaranteed a position with the Hospital at the same rate of pay. If an employee has been employed by the Hospital more than three years, the employee is eligible for long term disability benefits. These benefits guarantee the employee a position with the Hospital even after 90 days of leave of absence up to one year after the start of the leave but not necessarily at the same rate of pay. The Hospital's policy manual contains a second policy which relates to leaves of absence and which supplements the "30, 90, 365 day" policy and which Petitioner argues is somewhat inconsistent. The second policy states that the Hospital reserves the right to fill a vacancy created by a leave of absence but will make every effort to place an employee in a same or comparable position when he or she is able to return to work. The Hospital's experience in applying these policies to employees in comparable supervisory or management positions to Petitioner has been uniformly to bring those comparable employees, including Petitioner, back to a position in the Hospital other than the one they held prior to a leave of absence. Of the supervisory employees who have been on a leave of absence of more than 90 days, none has returned to the same position. This policy has been applied to employees with nonmedical leaves of absences as well as medical leaves. The Hospital has had numerous employees other than Petitioner take medical leaves of absence due to cancer conditions and return successfully from those leaves of absence to a position with the Hospital. At least one such person left the Hospital and came back to a higher position after a bout with cancer. Around January, 1987 and prior to the end of 365 days after her leave of absence began, Petitioner informed Ms. Reichert that she was released by her doctor, recovered from her cancer condition, was healthy and ready to return to work. However, the previous November, after consultation with Mr. Braun, Ms. Reichert had decided not to return Petitioner to the head nurse position of the I.V. team because of Petitioner's lack of success in managing the team. Instead, she decided to retain Ms. Hawkins on a permanent basis. Ms. Reichert did not make Ms. Hawkins appointment permanent until after Petitioner returned from her leave nor did Ms. Reichert tell Petitioner about her decision. Ms. Reichert felt that the announcement might cause a set back in Petitioner's recuperation. Ms. Reichert did tell Mr. Braun and Mr. Guilbault, however. Then, on January 19, 1987, Petitioner met with Ms. Reichert at the Hospital. They chatted for a while about the changes at the Hospital, but Ms. Reichert did not tell Petitioner about her decision not to return her to the I.V. team. She told Petitioner to show up ready for work in her lab coat on January 22, 1987, which Petitioner did. Ms. Reichert was convinced that Petitioner had fully recovered from her condition and was not suffering from a disability of any kind. Petitioner herself was convinced that she was fully recovered from her condition and was not suffering from any disability. On January 22, 1987, Ms. Reichert told Petitioner that she decided to replace her as head nurse because of her poor performance as manager which they had discussed on numerous occasions before Petitioner went out on her leave of absence. Instead, Ms. Reichert, being aware of the hospital's policy, offered Petitioner a staff nurse job at the same rate of pay as the head nurse position. Although a staff nurse is essential to patient care, appointment to a staff nurse position after having held a head nurse position was considered a demotion by Mr. Braun. Petitioner refused the position and met with Mr. Braun, who reviewed with her potential positions which the Petitioner was qualified to fill. Mr. Braun located three potential positions. Although the first two positions did not work out because of budget problems, Mr. Braun was acting in good faith in attempting to find a position for Petitioner. The third of the three options proposed by Mr. Braun, a home health I.V. position, showed more promise to Petitioner. Petitioner was asked to do a feasibility study on I.V. therapy as part of the home health agency. She began the study sometime in February, 1987 and worked on it for approximately two and one-half months until April, 1987. Numerous problems arose during the course of this feasibility study. In April, 1987, the Hospital determined that a home health I.V. therapy function was not economically feasible and decided not to pursue that matter further. At that point, the Hospital's top administrative staff and Mr. Braun met and made good faith review of all potential available positions for Petitioner. They were unable to locate a position for which the Petitioner was qualified other than a staff nurse position, for which there were numerous openings. Petitioner was re-offered a staff nurse position at her head nurse salary, even though under the Hospital policy, the Hospital was not required to continue to pay Petitioner her head nurse salary since she had been absent more than 90 days. Petitioner was also offered an orientation period and training to reacquaint her with floor nursing since she had been an administrative nurse for several years. Petitioner was unhappy with this offer. For the first time since she had been back to work, she complained of tingling and numbness in her hands as an excuse not to take the staff nurse position. Mr. Braun asked Petitioner for a doctor's report that she was capable of coming to work full-time, which she had obtained without any difficulty. Also, at the time that Ms. Reichert hired Petitioner in 1979, she was aware that Petitioner had suffered with back problems and had undergone one or more Pap smears. However, the proof failed to demonstrate any connection between these suggestions of problematic health and the employment decisions made by the Hospital concerning Petitioner. Consequently, the offer of a staff nurse position was renewed. The Petitioner declined the offer and declined to report to work on instructions from her attorney. Petitioner voluntarily left her employment at the Hospital. During the first years of her employment, Petitioner had received satisfactory to exemplary performance evaluations. Then, during her final full year, the year prior to her leave of absence, Petitioner received a less than satisfactory evaluation. However, the evaluation system at the hospital had changed during that time. The Hospital's evaluation system had undergone criticism because the assessments were too high and did not properly reflect an employee's performance. A new system was implemented. The system became more criteria based and resulted in lower evaluations throughout the Hospital. It was under this new system that Ms. Capron assessed Petitioner's performance during 1985, her last full year of employment. Unfortunately, due to Petitioner's illness and leave of absence, her evaluation for 1985 was not delivered to her or formalized until she returned from her illness in 1987. No credible evidence was offered at the hearing which suggested that Petitioner suffered from a handicap at the time the Hospital made the decision not to return her to the head nurse position in the I.V. therapy team. In fact, the decision was based on Petitioner's poor performance as a manager of the I.V. team.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is: RECOMMENDED that the Human Rights Commission issue a Final Order that Petitioner has failed to establish that Respondent discriminated against her on the basis of handicap in violation of the Human Rights Act of 1977, as amended. DONE AND ENTERED in Tallahassee, Leon County, Florida, this 27th day of April, 1990. JANE C. HAYMAN Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 27th day of April, 1990. APPENDIX TO RECOMMENDED ORDER, IN CASE NO. 89-4386 The following represents the rulings of the undersigned on the proposed findings of fact submitted by the parties. The rulings are listed by paragraph within the proposed findings of fact. PETITIONER Adopted in findings 2 and 25. Adopted in findings 2 and 25. Adopted, in relevant part, in findings 11, 17 and 23. Adopted in finding 13. Adopted, in part, in findings 14 and 18; in part, rejected as conclusion of law. Adopted in finding 20. Adopted, in part, in findings 15 and 16; in part, rejected as not supported by competent substantial evidence. Adopted, in relevant part, in finding 25. Rejected as not supported by competent substantial evidence. Adopted in finding 25. Rejected as not supported by competent substantial evidence, RESPONDENT Adopted as subordinate to the findings of fact. Adopted in finding 2. Adopted in finding 23. Adopted in finding 3. Adopted in finding 4, Adopted in finding 5. Adopted, in relevant part, in finding 6. Adopted, in relevant part, in finding 6. Adopted in finding 7. Adopted in finding 8. Adopted in finding 9. Adopted, in part, in finding 9. Adopted, in part, in finding 9. Adopted in finding 10. Adopted in finding 10. Adopted in finding 11. Adopted in finding 12. Adopted in finding 12. Adopted in finding 13. Adopted in finding 14. Adopted in finding 15. Adopted in finding 16. Adopted in finding 17. Adopted in finding 18. Adopted in finding 18. Adopted in relevant part in finding 20. Adopted in relevant part in finding 19. Adopted in finding 21. Adopted, in part, in finding 21; in part, rejected as not supported by competent substantial evidence. Adopted in finding 21. Adopted in finding 22. Adopted in finding 22. Adopted in finding 22. Adopted in finding 23. Adopted in finding 24. COPIES FURNISHED: Glen J. Torcivia, Esquire One Clearlake Centre, Suite 1404 250 Australian Avenue South, West Palm Beach, Florida 33401 Michael D. Malfitano, Esquire MacFarlane, Ferguson, Allison Kelly P.O. Box 1531 Tampa, Florida 33601 Donald A. Griffin Executive Director Human Relations Commission 325 John Knox Road Building F, Suite 240 Tallahassee, Florida 32399-1925 Dana Baird General Counsel Human Relations Commission 325 John Knox Road Building F, Suite 240 Tallahassee, Florida 32399-1925 Margaret Jones, Clerk Human Relations Commission 325 John Knox Road Building F, Suite 240 Tallahassee, Florida 32399-1925
The Issue The issue for consideration in this case is whether Respondent’s license to operate a nursing home should be disciplined because of the matters alleged in the Administrative Complaint filed herein, and whether the license issued to Respondent on October 1, 1995 should be conditional or standard.
Findings Of Fact At all times pertinent to the issues herein, the Agency for Health Care Administration, (Agency), was the governmental agency responsible for licensing and regulating the operation of nursing homes in Florida. Respondent operated a licensed nursing home known as Manhattan Convalescent Center, in Tampa. Consistent with its responsibility to conduct surveys (inspections) of nursing homes in this state, on June 16, 1995, the Agency conducted a complaint survey of the Respondent’s facility during which it noted a deficiency in staffing. This related to the surveyor’s determination that on May 22, 27, and 28, and on June 2, 3 and 6, 1995, there was “an underage of the state minimum CNA staffing requirements”. No citation was given for any violation of a state rule in this regard, nor was there any reference to a violation of state regulation. In addition, the matter was not noted as a “class” deficiency for state purposes under the provisions of Section 400.23, Florida Statutes. CNA’s, Certified Nursing Assistants, are answerable to nurses. Registered nurses, (RN’s), licensed practical nurses, (LPNs), and CNAs together constitute the nursing staff, which is responsible for direct resident care in a facility such as operated here by Respondent. All members of the nursing staff, regardless of classification, are responsible for hands-on resident care, such as bathing and feeding, and these duties are a part of the job description of not only CNAs but LPNs and RNs as well. The difference is that LPNs and RNs, depending on certification, are trained and authorized to provide additional, skilled care which a CNA is neither trained nor authorized to do. In other words, though a CNA can perform those functions which she or he is trained and licensed to do, a nurse, LPN or RN, can do and does those things within her or his training and certification which includes those things done by nurses lower on the scale. Nurses, either RNs or LPNs, employed at Manhattan are advised and understand that they are to perform CNA duties and cover for CNAs if a CNA does not come to work. If a nurse refuses or resists doing CNA work for any reason, the nurse is asked to leave the building. The Agency by rule has set a minimum level of CNAs per patient in nursing homes. The total number of CNAs required is figured by using a formula which multiplies the patient census for the day times 1.7 and divides the result by 7.5, the number of hours per shift worked by a CNA at Manhattan. The result is the number of CNAs required to be on duty on any given day. On July 31 and August 1, 1995, Elke Johnson, an RN specialist surveyor for the Agency, visited Manhattan for the purpose of following up on the complaint survey conducted in June, 1995. One of the allegations in the complaint was that patients were not being cared for. Ms. Johnson found this allegation to be unconfirmed. Nevertheless, as a part of the inspection, Ms. Johnson looked at the personnel records regarding CNA staffing for the two week period from June 16 through June 29, 1995 and did the calculation according to the cited formula for four days out of the 14. On all four days, she noted a shortage of CNAs. On July 15, 1995, there were 32 CNAs versus 38 required by patient census; 35 versus 38 on July 17, 1995; 35 versus 37 on July 22, 1995; and 25 versus 36 on July 23, 1995. When Ms. Johnson spoke about this finding with Manhattan’s director of nursing or assistant director of nursing, she was told that Manhattan was using licensed nurses, RNs or LPNs, to fill in for CNAs. The Agency claims that the director of nursing, Ms. Buble, stated that if licensed nurses were scheduled to do CNA work, that individual would be listed on the daily assignment sheet as a CNA so that the licensed nurse could receive assignments as a CNA. According to Ms. Johnson, however, even with the substitutions, there was still a shortage which Ms. Johnson classified as a deficiency. The Agency’s rule does not specifically provide for the use of RNs or LPNs in place of CNAs, but Ms. Johnson considered such a substitution to be appropriate. Accepting that, however, as was noted previously, Ms. Johnson still noted a deficiency in numbers. Though Ms. Johnson did not participate in the December 1995 follow-up inspection, on her visit to the facility in April 1996, she found the staffing deficiency had been cleared and no violations existed at that time. Two complaints involving staffing in September and November 1995 caused a reinspection of the facility by Susanne Emond of the Agency on December 5, 1995. Ms. Emond worked with the director of nursing, Ms. Buble, the entire day and went over the patient census sheets with her as well as the assignment sheets. At that time the documents provided by Manhattan reflected that it was required to have 37 CNAs on duty each day between September 12 through September 16, 1995, but in reality had only 32.5 CNAs on duty on September 12; 32 on September 13; 32 on September 14; 34 on September 15 and 32 on September 16, 1995. In addition, Manhattan was required to have more than 35 CNAs on duty each day between November 9 through 12, 1995 but had only 27.5, 28, 30 and 32.5 on November 9, 10, 11 and 12, 1995, respectively. As was previously stated, the determination of a CNA shortage was based upon a consideration of numbers generated by the surveyor in consultation with the then director of nursing, Ms. Buble. The compilation by Ms. Buble was made utilizing only the assignment sheets, and did not consider any extra hours which were worked by on-duty personnel which was reflected on the sign- in sheets, rather than the assignment sheets. Respondent claims, therefore, that the documentation provided to the surveyor by Ms. Buble was not accurate. Gary Janovsky is a RN specialist with the Agency who inspected Manhattan on June 16, 1995. During the course of his visit he checked the staffing levels relating to CNAs for May 22,27 and 28, and June 2,3 and 6, 1995, and using the appropriate formula as applied to the sign-in sheets provided by the Respondent, concluded there was a shortage on all six days whether one considered an 8 hour shift or a 7.5 hours shift. Jerry Alfieri has been the director of nursing at Manhattan since March 23, 1996 and was in place there during the follow-up inspections. He has worked as a director of nursing in a nursing home for 4 years. Before he got to Manhattan it was Respondent’s policy to heavily overstaff with licensed nurses to make up for shortages of CNAs, of which there is a shortage in the area. When he took over as director of nursing, he reviewed all staffing records from January 1995 up to date and found an adequate number of CNAs were hired and assigned, but from time to time, there was an attendance problem with that category of employee. It got so bad that at times, up to 10 CNAs per day would call in to be absent, and when this would happen, he would assign LPNs or RNs to CNA duties. He contends this was not made clear to the surveyors. Mr. Alfieri believes this is now clear to the Agency and his office is following the same procedure now, without problem, and was being followed at the time of the surveys which resulted in the filing of deficiencies. Mr. Alfieri reviews his staffing figures on a daily basis looking at hours worked, not bodies. When that procedure is followed, one sees that on May 22, 1995, Manhattan was 139.1 hours over requirement and, he believes, a review of every day in issue but one, July 23, 1995, will show an overage of hours for the facility. On that day, Manhattan was 21 hours low, a shortage of 3%. Mr. Alfieri takes the position not that the number of CNAs on duty was up to the Agency’s standard, but that adequate nursing hours were provided to meet the requirement, and there was no complaint sustained regarding a lack of patient care. In September 1995, for example a listing by date of nursing hours over standard shows: 9/12 103 9/13 36 9/14 77 9/15 15 11/9 93 11/10 201 11/11 4.7 11/12 27.92 It should be noted that on November 11, 1996, though 6 CNAs called in absent, Manhattan still had 4.7 hours of nursing care over standard. According to Mr. Alfieri, licensed nurses at Manhattan are assigned a certain set of patients and they are to insure that those patients get whatever care is necessary. If a CNA can do a procedure, its done by a CNA, or by a licensed nurse if a CNA is not available. That statement is confirmed by Robin Grab, nurse manager of station 1 (the Medicare unit of 42 beds) at Manhattan for 6 years. She has been an LPN for more than 19 years. According to Ms. Grab, from time to time CNAs call in absent, and when this happens, the licensed nurses do rounds and assist in doing whatever is needed to provide patient care. It is a part of their job duties and if a licensed nurse refuses to do anything asked, that individual is asked to leave. As a result, RNs and LPNs regularly assist and are involved in activities of daily living, (ADL), and answering call lights. If a licensed nurse has to do CNA work, the nurse is so told. When a shortage of CNAs appears imminent, an attempt is made to call in more CNAs, but, if necessary, RNs and LPNs are called in to fill vacancies of CNAs. When William Scheller, Manhattan’s administrator, first came to the facility he was made aware of the inadequate number of CNAs. To correct this, he started the practice of using licensed nurses to make up the shortage. He also hired additional licensed staff to make up for call-outs, paid bonuses and recruited staff from other facilities. Manhattan pays its nurses and CNAs competitive wages. At no time has it ever intentionally understaffed with CNAs. To do so does not make sense because it costs more for licensed nurses than for CNAs. He insures that licensed personnel perform CNA duties when required by personal checks by him and his staff. Unit managers are responsible to insure that patients get adequate care and if staff is insufficient, they try to bring in additional people. The documentation used to record nursing staffing was changed in early 1996 to conform to Agency direction as to how it should be done. These documentation changes did not change coverage practices, however, as those practices were, he contends, up to standard all along.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Agency for Health Care Administration enter a final order finding that Respondent did not fail to meet staffing requirements sufficient to ensure each resident maintained his or her highest practicable level of well- being, but that it did fail to have an average of 1.7 hours of certified nursing assistant time for each resident during at least eight 24 hour periods, and assessing an administrative fine of $250.00. It is further recommended that the Agency correct its records to reflect Respondent’s entitlement to a standard license rating effective October 1, 1995. DONE and ENTERED this 12th day of March, 1997, in Tallahassee, Florida. ARNOLD H. POLLOCK Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (904) 488-9675 SUNCOM 278-9675 Fax Filing (904) 921-6947 Filed with the Clerk of the Division of Administrative Hearings this 12th day of March, 1997. COPIES FURNISHED: Thomas W. Caufman, Esquire Agency for Health Care Administration 7827 North Dale Mabry Highway Tampa, Florida 33614 Donna H. Stinson, Esquire Broad and Cassel 215 S. Monroe Street, Suite 400 Post Office Drawer 11300 Tallahassee, Florida 32302 Sam Power Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32308 Jerome W. Hoffman General Counsel Agency for Health Care Administration 2727 Mahan Drive Tallahassee, Florida 32309
The Issue The issue in the case is whether the allegations in the Administrative Complaint, as amended, are correct and if so what penalty is appropriate.
Findings Of Fact The Petitioner is the state agency charged with responsibility for regulation of licensed nursing home administrators in Florida. At all times material to this case, the Respondent was a licensed nursing home administrator. On or about April 13, 1998, the Respondent was hired as the administrator of the “Colonial Oaks” nursing facility (the facility) located in Ft. Myers, Florida. The facility was owned by Vencor and had been operating for about four years by the time the Respondent became the administrator. Prior to her move to Colonial Oaks, the Respondent had 20 years of experience as a nursing home administrator. The Respondent’s previous nursing home employment had been at facilities with superior ratings. She agreed to transfer to this facility because she believed that she could improve the situation and secure a superior rating for it as well. She has never been the subject of a disciplinary proceeding prior to this case. Colonial Oaks had been through 12 administrators and 15 directors of nursing before the Respondent assumed the administrator’s position. There were considerable staff problems at the facility. Continuing management difficulties made if difficult to motivate staff members who apparently assumed that the managers would soon be gone and that new managers with new expectations would arrive. Further staffing problems were related to the type of patients who resided at Colonial Oaks. The facility drew a large population of private pay residents who expected high levels of service from the staff, which the staff was apparently unable or unwilling to provide. At the time of the Respondent’s employment at the facility, there was no director of social services and no director of activities. Additionally, resignations had been submitted by the medical records coordinator, the care plan coordinator, the staff development coordinator, the therapy director, the case manager, and the central supply clerk, all of whom were completing their resignation notice periods. Immediately upon beginning her tenure at the facility, the Respondent began to advertise the job openings in an attempt to fill the positions. She filled a number of open positions and began training new employees. She met with the staff frequently and made daily rounds to review the operation of the facility. Employees seeking to become Certified Nursing Assistants were offered classes to encourage them to complete their training. The Respondent also changed the resident care plan records program from a computerized system, which was allegedly disliked by survey teams from the Agency for Health Care Administration (AHCA) responsible for inspecting the facility, to a paper-based system which provided for easier review by survey teams. There is no evidence that the Respondent failed to make an appropriate effort to address the problems existing at the facility when she assumed control. AHCA inspectors surveyed the facility on August 6 through 8, 1998. While the survey team inspected the facility, the Respondent spent much of the time in her office preparing a package she expected to submit to the survey team which she believed would lead to a superior rating. She also responded to requests for information from the survey team. According to the survey report, the survey team identified numerous deficiencies. The facility received a conditional rating. Among the cited deficiencies were instances where residents were allegedly left in soiled clothing for extended periods of time. Some of the allegations involved residents with skin irritation or sores which could be exacerbated by unsanitary clothing. The facility’s policy and procedure require that residents be “repositioned” every two hours and that incontinent residents should be changed every two hours. Based on the testimony of William Sullivan, the evidence establishes that in at least one case of an incontinent resident sitting in a wheelchair, the facility did not comply with the policy and procedure requirement that he be moved and changed every two hours. Based on the testimony of Joan Cagley-Knight, the evidence establishes that in at least one case of an incontinent resident with a “full diaper,” the facility did not comply with the policy and procedure requirement that the resident be changed every two hours. There is no evidence that the Respondent was aware that some employees of the facility failed to comply with the policy and procedure requirement that the resident be changed every two hours. According to the survey report, other alleged deficiencies included weight loss by some residents. There is no evidence that prior to the August survey, the Respondent was aware that some residents were losing weight. The weight of the evidence fails to establish that the Respondent should have known that some residents were losing weight. According to the survey report, other alleged deficiencies included random complaints voiced by some relatives of facility residents. The Respondent maintained an “open door” policy so that any person could meet with her and address matters of concern. There is no evidence that prior to the survey, the Respondent was aware of any unresolved relative complaints that had not been addressed. Colonial Oaks had been rated “conditional” previously and was described by the Vencor employee who followed the Respondent as a “yo-yo facility” which would sometimes improve and then falter. The Respondent prepared a plan of correction to address the deficiencies. The plan of correction was apparently approved by AHCA and was implemented by the Respondent. The corporate owner of the facility did not challenge any of the cited deficiencies through a procedure known as Informal Dispute Resolution (IDR). The Respondent was not involved in the decision not to utilize the IDR process. Subsequent to the August survey, the facility’s director of nursing resigned. The Respondent made attempts to hire a new director of nursing. She requested that the corporate owner assist in the search, which extended outside the State of Florida. Apparently the troubled reputation of the facility made it difficult to convince prospective nursing directors to accept the position. Regional nurses assigned by Vencor to assist in the situation resigned rather than work in the facility. Eventually, the Respondent’s immediate supervisor came in to assist with the problems. The supervisor brought in some additional corporate employees including nutritionists, but most refused to become involved in the turmoil. On October 6, 1998, an AHCA team resurveyed the facility. At the time of the October survey, the nursing director was still serving out her resignation notice period. Although as of the October 6 survey a number of deficiencies had been corrected, several deficiencies were again cited. The cited deficiencies included instances where residents were allegedly left in soiled clothing for extended periods of time. In at least one case, based on the testimony of Joan Cagley-Knight, an incontinent resident sat in urine- soaked sweatpants for more than two hours without being assisted by an employee of the facility, in violation of the applicable policy and procedure requirement. The weight of the evidence fails to establish that the Respondent knew or should have known that some employees of the facility failed to comply with the policy and procedure requirement that the resident be changed every two hours. Based on the testimony of William Sullivan, the evidence establishes that some residents continued to lose weight and that nutritional recommendations were not being implemented. There is no evidence that the Respondent was aware that the nutritional issues had not been addressed, after corporate nutritional specialists were brought in following the August survey. There was also an issue related to an injury suffered by a resident who fell while unrestrained. The issue related specifically to an apparently incorrect report made by the facility’s director of nursing to AHCA officials regarding the site where the accident occurred. There is no evidence that the Respondent attempted to mislead the AHCA employees about the incident in any manner. On October 9, 1998, the Respondent transferred to the “Windsor Woods” facility, a superior-rated facility also owned by Vencor, where she continued to achieve a superior rating until the rating program was discontinued.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department of Health, Board of Nursing Home Administrators, enter a final order dismissing the Administrative Complaint, as amended, filed against Janice Carol Reeping. DONE AND ENTERED this 30th day of October, 2001, in Tallahassee, Leon County, Florida. ___________________________________ WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 30th day of October, 2001. COPIES FURNISHED: Karen L. Goldsmith, Esquire Goldsmith & Grout, P.A. 2180 North Park Avenue, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Mary Denise O'Brien, Esquire Department of Health 2727 Mahan Drive, Mail Stop 39 Tallahassee, Florida 32308 John Taylor, R.Ph., Executive Director Board of Nursing Home Administrators Department of Health 4052 Bald Cypress Way, Bin C04 Tallahassee, Florida 32399-1701 Theodore M. Henderson, Agency Clerk Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701 William W. Large, General Counsel Department of Health 4052 Bald Cypress Way, Bin A02 Tallahassee, Florida 32399-1701
The Issue Was Petitioner properly cited for a Class III deficiency.
Findings Of Fact Horizon Healthcare & Specialty Center (Horizon), is an 84-bed nursing home located at 1350 South Nova Road, Daytona Beach, Florida. It is licensed under Chapter 400, Part II, Florida Statutes. The Agency for Health Care Administration (AHCA) is the state agency charged with licensing and regulating nursing homes in Florida. On August 14, 2000, AHCA conducted a survey of Horizon. This was accomplished in part by Rose Dalton, a nurse. At the hearing Ms. Dalton was determined to be an expert in nursing care. A report on a nursing home survey is made on a Form 2567-L which is approved by the U.S. Department of Health and Human Services, Health Care Financing Administration. A Form 2567-L was generated as a result of Ms. Dalton's survey. It was reported under the category Tag 327. Resident 7. Ms. Dalton, in conjunction with the survey team accompanying her, determined on August 17, 2000, that Resident 7 was dehydrated. This conclusion was reached because facility records indicated that Patient 7 had a blood urea nitrogen (BUN) of 57 on August 7, 2000, with normal being 6-26, and a high normal creatinine of 1.6. Another factor used in concluding that Resident 7 was dehydrated was a report dated August 8, 2000, which revealed a BUN of 34. On August 12, 2000, a report indicated a BUN of 43 and a creatinine of 1.9. The survey team was also aware that Resident 7 was ingesting Levaquin, a powerful antibiotic which requires that a patient remain well-hydrated. Ms. Dalton and the survey team cited the facility with a Class III deficiency, for state purposes, and a "G" on the federal scale. The federal scale goes from "A", which is a deficiency which causes no harm, to "J", which is harm which may cause death. The "G" level meant that it was the team's opinion that there was great potential for actual harm. Resident 7 was admitted on August 3, 2000. Among other ailments, Resident 7 was suffering from a femoral neck fracture and renal insufficiency when admitted. The resident contracted a urinary tract infection (UTI), and was being administered Levaquin, an antibiotic appropriate for UTI treatment. On August 8, 2000, a physician's order requested that the patient be encouraged to consume fluids. It is Ms. Dalton's opinion that Resident 7 was not provided proper fluid intake by the facility which could have caused serious health consequences for Resident 7. When Resident 7 was in the hospital, prior to being admitted to Horizon, his BUN was 41 and his creatinine was 2.3, which is consistent with Resident 7's chronic renal insufficiency. The BUN of 43 and creatinine of 1.9 observed in the facility on August 12, 2000, did not indicate Resident 7's condition was worsening, and in fact, it was improving marginally. The values for a normal BUN might vary from laboratory to laboratory but generally a normal BUN would be around 25 or less. Because of Resident 7's underlying renal disease and ischemic cardiomyopathy, it was unlikely that Resident 7 would ever manifest a BUN which would be considered normal. Dr. Elizabeth Ann Eads, D.O., an expert in the field of geriatric medicine, reviewed the laboratory values and the nursing notes in the case of Resident 7. It is her opinion, based on that review, that the facility provided appropriate care, that the patient improved during the stay at the facility, and that there was nothing in the record which suggested any actual harm to Resident 7. This opinion was accepted. Resident 8. Ms. Dalton opined that, based on her personal observation and a review of Resident 8's medical records, that the facility failed to respond to the hydration needs of Resident 8 and did not follow the care plan which was developed for Resident 8. Ms. Kala Fuhrmann was determined to be an expert in the field of long-term care nursing. She noted that Resident 8 was admitted to the facility on August 1, 2000. Resident 8's hospital records indicated that Resident 8 might be developing a UTI based on a urinalysis performed on July 31, 2000, which revealed blood and protein in the urine. On August 3, 2000, Resident 8's doctor started an antibiotic, Levaquin, and ordered another urinalysis. On August 4, 2000, a culture determined that Resident 8 was positive for a UTI, so the antibiotic treatment was continued. On August 15, 2000, it was determined the UTI had been cured. During the course of the UTI, Resident 8 was incontinent, which is often the case when elderly patients are afflicted with UTI. By August 18, 2000, Resident 8 was continent. It is Ms. Fuhrmann's opinion that the care provided to Resident 8 was appropriate and that there is nothing in the record which demonstrates that anything less than adequate hydration was provided to this resident. This opinion was accepted.
Recommendation Based upon the Findings of Fact and Conclusions of Law, RECOMMENDED: That the Agency for Health Care Administration enter a final order dismissing the allegations set forth in relation to the TAG 327. DONE AND ENTERED this 12th day of June, 2001, in Tallahassee, Leon County, Florida. HARRY L. HOOPER Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 12th day of June, 2001. COPIES FURNISHED: Karen L. Goldsmith, Esquire Goldsmith & Grout, P.A. 2180 North Park Avenue, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Michael O. Mathis, Esquire Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three, Suite 3431 Tallahassee, Florida 32308-5403 Sam Power, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three, Suite 3431 Tallahassee, Florida 32308 Julie Gallagher, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building Three, Suite 3431 Tallahassee, Florida 32308
