The Issue The issue presented for decision in this case is whether a civil penalty in the amount of $1,400.00 should be imposed on the Respondent for the repeated deficiencies cited in the Administrative Complaint dated September 14, 1998.
Findings Of Fact Based on the oral and documentary evidence adduced at the final hearing, and the entire record in this proceeding, the following findings of fact are made: Respondent, Heartland of Zephyrhills ("Heartland"), is a nursing home licensed by and subject to regulation by AHCA, pursuant to Chapter 400, Florida Statutes. Section 400.23(8), Florida Statutes, requires AHCA to evaluate all nursing home facilities and make a determination as to their degree of compliance with the established rules at least every 15 months. The inspection and evaluation is to ensure compliance with applicable state and federal standards. The standards relevant to this case are 42 Code of Federal Regulations (C.F.R.) Section 483.25(c), Florida Statutes, and Rule 59A-4.128, Florida Administrative Code. On August 17-20, 1998, AHCA surveyed Heartland and allegedly found violations of 42 C.F.R. Section 483.25(c), Florida Statutes, which states that a facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the resident’s clinical condition demonstrates that they were unavoidable, and that a resident having pressure sores receives necessary treatment to promote healing, prevent infection, and prevent new sores from developing. In the parlance of the Federal Health Care Financing Administration Form 2567 ("Form 2567") employed by AHCA to report its findings, this requirement is referenced as "F 314" or "Tag 314." Katherine Robbins is a Registered Nurse with over 20 years experience, including working as a director of nursing in an 86-bed nursing home. She is a federally certified surveyor, and now works for AHCA as a surveyor of long-term care facilities such as nursing homes. Ms. Robbins performed a portion of the survey of Heartland and wrote the deficiency notes under Tag 314 for Resident No. 1. Resident No. 1 was admitted to Heartland on January 29, 1998, with a diagnosis of dementia, osteoarthritis, anxiety, and depression. Ms. Robbins testified that diagnoses of dementia and osteoarthritis indicate a predisposition to the development of pressure sores. She testified that a diagnosis of anxiety could indicate a predisposition to pressure sores, if the patient is receiving psychoactive medications. The initial skin assessment on Resident No. 1 indicated there was no skin breakdown at the time she was admitted. Review of the patient records indicated that skin breakdown was evident on July 26, 1998, when a stage II pressure sore on the coccyx was reported. Pressure sores are graded on a scale from stage I for the least severe to stage IV for the most severe. On August 5, 1998, the facility developed a care plan to deal with the skin breakdown and prevent further breakdown caused by Resident No. 1’s decreased mobility, medications, and lack of awareness of her own needs. The resident was completely unable to care for herself, and was unable to get in and out of a chair or the bed on her own. The approaches set forth in the plan included changing the resident after each incontinent episode, increasing her intake of protein foods, and naps in the afternoon to relieve sitting pressure on the coccyx. Ms. Robbins testified that this plan was not adequate in all respects, but would have been workable had it been properly implemented. On August 17, 1998, the first day of the survey, Resident No. 1 was observed at 9:20 a.m. sitting in a wheelchair in her room. She was observed sitting in the activity room from 11:35 a.m. until 12:50 p.m., at which time she was taken to the dining room for lunch. Following lunch, she was observed sitting in her wheelchair without a change in position until 3:20 p.m., when she was taken to the shower room for a shower. Ms. Robbins testified that allowing the resident to sit in the same position would create pressure on the coccyx, where the resident already had a pressure sore. It is routine preventive care to reposition a resident who has a pressure sore or is at risk of developing pressure sores. On August 18, 1998, Resident No. 1 was observed in her room, sitting in a wheelchair and eating breakfast at 8:15 a.m. She was observed at 12:40 p.m. in the dining room, sitting in a chair without a pressure relieving air flotation jell cushion. Ms. Robbins testified that use of such a cushion would be good practice to help heal a pressure sore. Ms. Robbins testified that she asked the director of nursing about this situation, and that the director of nursing told her that Resident No. 1 was sitting in the wrong chair. The clinical record showed that wheelchair modifications had been included in Resident No. 1’s physical therapy plan, but the resident was not placed in the correct chair. Therapy notes indicated that the goal for the resident was to have a chair that would prevent posterior pelvic pressure and lower the seat so that the resident could maneuver the wheelchair safely. The resident would be able to tolerate sitting up in the wheelchair for three or four hours with repositioning being provided every two hours for bathroom needs and pressure relief. The care plan for Resident No. 1 also called for her to be assisted to bed for a nap in the afternoon. Ms. Robbins observed that the resident was not taken for a nap on either August 17 or August 18, 1998. The survey team made a collective decision to cite the Tag 314 deficiency as a class II deficiency, because the stated care plan for the resident was not followed and this was a repeat licensure deficiency. A class II deficiency is subject to a civil penalty of not less than $1,000. However, the Administrative Complaint erroneously cited this as a class III deficiency and recommended a civil penalty of only $700. The August 17-20, 1998, survey also found alleged violations of Life Safety Code ("LSC") standards set forth by the National Fire Protection Association ("NFPA"), in particular NFPA 90A LSC 12-5.2.1 and 13-5.2.1 air conditioning and ventilation standards. In the parlance of Form 2567, this requirement is referenced as "K 067." Peter Cranfield is a fire protection specialist employed by AHCA. He has over 35 years experience in the design, installation, and sales of fire protection systems, mostly in the private sector, including fire protection systems for nursing homes. Mr. Cranfield participated in the survey of Heartland and cited the facility for the K 067 deficiency. Mr. Cranfield found that the following areas of the facility did not have an operable exhaust ventilation system: the main dietary and dishwasher independent units; the No. 300 wing nurse station toilet room; and the No. 400 wing and No. 100 wing janitor closets. Mr. Cranfield brought these deficiencies to the attention of Heartland’s maintenance director, who agreed upon examination that the exhaust units did not appear to be operational. Mr. Cranfield testified that the maintenance director later told him an electrical malfunction was causing the problem. The K 067 deficiency was noted as a repeat class III citation.
Recommendation Upon the foregoing findings of fact and conclusions of law, it is recommended that the Agency for Health Care Administration enter a final order requiring Heartland of Zephyrhills to pay a civil penalty in the amount of $1,400 for the two cited class III deficiencies. DONE AND ENTERED this 25th day of March, 1999, in Tallahassee, Leon County, Florida. LAWRENCE P. STEVENSON 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 25th day of March, 1999. COPIES FURNISHED: Karel Baarslag, Esquire Agency for Health Care Administration 2295 Victoria Avenue Fort Myers, Florida 33906 Terrie Restivo-Mock, Esquire Heartland of Zephyrhills 38220 Henry Drive Zephyrhills, Florida 33540 Sam Power, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308 Paul J. Martin, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
The Issue Are Petitioner’s outside water supply connections in violation of Rule 10D-26.120(2) and (3)(a), Florida Administrative Code, and, if so, should Petitioner be assessed an administrative fine for such violation?
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: Petitioner is permitted by the Department in accordance with Chapter 513, Florida Statutes, to operate the Peace River Campground, (Campground) which is a Recreational Vehicle (RV) Park (182 spaces) and a Mobile Home (MH) Park (15 spaces), annual permit number 14-010-97. The Campground’s water is supplied by a community public water utility company. Each RV and MH space has an outside water tap as required by Chapter 10D-26, Florida Administrative Code. Many of the outside water taps do not have a backflow or back-siphonage prevention device installed on them. On February 6, 1997, the Department conducted a routine inspection of the campground and determined that the campground was in violation of Rule 10D-26.120(2) and (3)(a), Florida Administrative Code, for failing to have the required backflow or back-siphonage prevention. The citation required Petitioner to install backflow or back-siphonage prevention by February 28, 1997, the next scheduled inspection date. On February 28, 1997, the Department conducted a follow-up inspection of the Campground’s water system and determined that the alleged violation had not been corrected. Petitioner disagreed with the Department’s determination that the Campground’s water system was not in compliance with Rule 10D-26.120(2) and (3)(a), Florida Administrative Code, for failing to have the Campground’s water system designed or constructed to prevent backflow or back-siphonage. On February 28, 1997, the Department issued a citation of violation (citation) to Petitioner alleging a violation of Rule 10D-26.120(2) and (3)(a), Florida Administrative Code, for failing to have the Campground’s water supply connection designed or constructed to prevent backflow or back-siphonage. The Campground’s water connections at each RV and MH site have water taps which are above ground and have standard water shut-off valves. The Campground’s water system has good water pressure of approximate 70-100 pounds pressure per square inch (psi). The Campground’s outside water taps are neither constructed nor designed to prevent backflow or back-siphonage in the event the water pressure drops to a point which would allow backflow or back-siphonage, such as if the water main feeding the Campground’s water system broke. If the water pressure in the Campground’s water system should drop allowing backflow or back-siphonage, hazardous material could possible be injected in the water system. Although there has never been a recorded incident of backflow or back-siphonage into the Campground’s water system, without the some type of backflow or back-siphonage preventer being installed there remains a potential for this to happen. The Campground’s outside water connections would not prevent backflow or back-siphonage under certain conditions and are not in compliance with Rule 10D-26.120(2) and (3)(a), Florida Administrative Code. There are six basic types of devices that are recognized by the Environmental Protection Agency and the engineering profession which prevent backflow and back-siphonage. These devices are: (a) air gaps; (b) barometric loops; (c) vacuum breakers--both atmospheric and pressure type; (d) double check with intermediate atmospheric vent; (e) double check valve assembler; and (f) reduced pressure principle devices. The Department does not mandate which device the Petitioner must install, only that a proper device be installed which will prevent backflow or back-siphonage. A hose bib vacuum breaker such as Department’s Exhibit 3 provide the minimum protection against backflow or back-siphonage and is considered acceptable for compliance with Rule 10D- 26.120(2) and (3)(a), Florida Administrative Code.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Department enter a Final Order assessing an administrative fine in the amount of $150.00. DONE AND ENTERED this 27th day of August, 1997, in Tallahassee, Leon County, Florida. _ WILLIAM R. CAVE 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 27th day of August, 1997. COPIES FURNISHED: Susan Martin Scott, Esquire Department of Health Post Office Box 60085 Fort Myers, Florida 33906 George Lempenau, pro se Peace River Campground 2998 Northwest Highway 70 Arcadia, Florida 34266 Angela T. Hall, Agency Clerk Department of Health 1317 Winewood Boulevard Building 6 Tallahassee, Florida 32399-0700
The Issue The issue posed herein is whether or not the Petitioner's imposition of a civil penalty upon Respondent in the amount of $750.00, based on conduct which is set forth hereinafter in detail, should be upheld.
Findings Of Fact Based on the testimony of the witnesses and their demeanor while testifying, the arguments of counsel and Respondent's representative, the documentary evidence received and the entire record compiled herein, the following relevant facts are found. On October 2 and 3, 1979, Petitioner's inspection team led by Jules M. Gayle, Hospital Consultant, made a routine annual inspection of Hollywood Hills Nursing Home (herein sometimes called Respondent or the Home). Based on this inspection, Respondent was issued a list of deficiencies and allowed thru October 6, 1979 to correct same. The deficiencies cited were: A patient in Room #4 had oxygen in use with an improperly grounded electric lamp in use. A patient in Room #61 had oxygen tank in use not properly secured to a base pedestal and an electric clock located on a table next to tank was improperly grounded. The oxygen storage room on the second floor, opposite the elevator shaft, had one tank of oxygen not firmly secured on chain attachment; a prefilled humidifier attachment was left exposed to air, dust and possible bacteria contamination. A full oxygen tank stored within the first floor storage area exhibited a cannula attachment to a prefilled humidifier bottle not encased in any protective covering with the nasal apertures dangling from the tank and resting upon the dirty floor. Approximately 20-23 patients in wheelchairs were observed obstructing the first floor corridor passageway, and a similar situation existed on the second floor corridor, a hazard in the event of an emergency. Two psychiatric hospital or maximum security seclusion rooms, located within the nursing home proper, pose a potential hazard to nursing home patients and to staff. The toilet room ceiling in patient Room #65 was covered with a green mold fungus growth. A follow-up inspection of the home on November 15, 1979 indicated that, with the exception of the mass assembly of patients in the corridor, the cited deficiencies were not corrected. (Testimony of Jules M. Gayle). Based on the results of the follow-up inspection, Respondent was noticed by Petitioner's Administrative Complaint dated February 21, 1980, that a $750.00 fine would be imposed. The Home is a 200 bed facility which is licensed to care for 100 psychiatric and 100 regular patients in need of nursing care. All of the beds (psychiatric and general) are housed under one roof with a security door divider. RESPONDENT'S DEFENSE Messr. Steve M. Raizin, Administrator for the Home related that the Home has a policy of correcting deficiencies as soon as practicable. As examples of this policy, the Administrator pointed out that a dietician was replaced when criticism arose respecting unsanitary conditions of the kitchen and the improper dispensing of food; a roof replacement at a cost of approximately $40,000 when the Home was cited and the purchase of a dumpster for trash and refuse at a cost to the Home of $10,000. The Home immediately removed the improperly grounded electrical lamp and radio from the patients room. The large congregation of patients in the corridor was a result of patients being transferred from the activity room to the cafeteria. The Administrator has attempted to convert the psychiatric seclusion rooms but has encountered resistence and opposition by the local Health Planning Council and the Courts. Finally Respondent has, according to the Administrator, taken steps (unspecified) to ensure the safety of all patients. Even assuming that Respondent has taken the corrective actions set out above, there remains outstanding deficiencies which, as best as can be determined by the record, remain uncorrected. For example, it appears that the cited problem of an unsecured oxygen tank still exists. No mention was made by Respondent's Administrator as to what, if any, corrective action was taken to cover the exposed prefilled humidifier attachment and the fungus growth in the toilet of Room 65. That being the case, in view of the record evidence that these problems exist, it can only be concluded that the deficiencies remain (Petitioners Composite Exhibit #1 and Testimony of Jules M. Gayle). Any one of the above deficiencies amount to a violation of Section 400.141(4)(h), Florida Statutes, for which Respondent is subject to a civil penalty of not less than $500.00 and not more than $1,000.00 for each deficiency. I shall therefore recommend that Petitioner's imposition of a $750.00 civil penalty be upheld.
Recommendation Based on the Foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED: That the Petitioner's imposition of a civil penalty in the amount of $750.00 be UPHELD. RECOMMENDED this 21st day of July, 1980, in Tallahassee, Florida. JAMES E. BRADWELL 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 21st day of July, 1980. COPIES FURNISHED: Harold Braynon, Esquire District X Legal Counsel Department of Health and Rehabilitative Services 201 West Broward Boulevard Fort Lauderdale, Florida 33301 Steve M. Raizin, M.H.A. Administrator Hollywood Hills Nursing Home 1200 North Thirty-fifth Avenue Hollywood, Florida 33021
