The Issue Whether or not Petitioner may impose an administrative fine on Respondent DOS of Crystal River, ALF, LLC d/b/a Crystal Gem ALF (Crystal Gem) in the amount of $2,000.00 based upon two cited State Class II deficiencies pursuant to Section 429.19(2)(b), Florida Statutes (2007).
Findings Of Fact Petitioner AHCA is the state agency responsible for licensing and evaluating assisted living facilities (ALFs), pursuant to Sections 408.802(14) and 429.07, Florida Statutes. Respondent Crystal Gem is an ALF located in Crystal River, Florida. Resident No. One, hereafter referred to as “the resident,” resided in Respondent ALF from April 5, 2007, to April 10, 2007. The resident had fallen in her bedroom in the home she shared with her daughter, son-in-law, and grandson at approximately 2:00 a.m. on the morning of April 4, 2007. By all accounts, prior to this accident, the resident was active, orally communicative, capable of performing all activities of daily living (ADLs), and contributed to the household by doing familial household work. She had suffered a single episode of dementia in the past. She was known to drink large quantities of water but did not eat a lot at any one meal. She loved to eat and regularly ate between meals. After the fall, the resident had gotten back into bed by herself, but had been in a lot pain. Her family assisted her to walk out of the house to the family car. They took her to Citrus Memorial Hospital, where she walked, with assistance, into the emergency room. She was placed in a wheelchair and completed her own admission papers. Hospital records from April 4, 2007, indicate the resident was 84 years old; had a heart valve replacement; and had been fitted with a pacemaker. She weighed 91 pounds and was underweight. She was suffering from osteoporosis, arteriosclerosis, and chronic obstructive pulmonary disease (COPD). The hospital records noted abrasions and tenderness on her left back. X-rays were taken of her ribs. The preliminary report of the hospital’s diagnostic imaging department indicated non-displaced fractures to her left eighth and ninth ribs. The records do not indicate that any other x-rays were taken at that time. The resident’s right hip, where a fracture was later found (see Finding of Fact 56), was not x-rayed on April 4, 2007. The resident was sent home from the hospital with a prescription of the narcotic, Hydrocodone (a generic for Vicodin), for pain relief. The prescription was later filled. Exiting the emergency room on April 4, 2007, the resident walked, with assistance, back to the family car for transport home and walked into the family home the same way. The family had planned to leave on April 5, 2007, for an out-of-town family celebration. Due to the possibility that the resident’s ribs might break further and puncture her lungs, the hospital doctors had recommended that she not travel by car with her family. After consultation with the resident’s personal physician, weighing all options, a tour of the facility by the daughter, and upon good recommendations, the family elected, with the resident’s consent, to place the resident in Respondent’s ALF for respite care while they were out of town. By all accounts, the resident was in some discomfort, but functioned normally in the family home all of April 4, 2007, during which time she continued to do familial household chores, and on the morning of April 5, 2007, before departing for Respondent’s facility. On both days, she was not confused; was able to bathe herself; and had no diminished intake of either food or liquids. The resident’s daughter escorted her to Respondent facility on the morning of April 5, 2007. (Stipulated) The two women arrived at the facility about 10:00 a.m. on April 5, 2007, and during an extensive tour of the first floor (both inside and outside), the resident was able to ambulate and did not complain of pain. The facility’s Resident Assessment Data Collection Form, filled out upon her admission into the facility, stated the resident was ambulatory with one- person assist and full weight-bearing, with bruising and discomfort on the right side. It further noted that she needed assistance in transferring and in ambulating. The facility's Observation Log for that day described her as "extremely small and frail with poor balance and needs to be monitored closely during ambulation." The Observation Log is used by Respondent to record each resident's condition and activities as observed by staff. Upon the resident’s admission, Respondent facility was provided only with the resident’s April 4, 2007, hospital discharge instructions and hospital emergency department after- care instructions. These indicated “fall/rib fracture,” and did not specify which ribs were fractured. Nothing on them related to either hip. The hospital discharge instructions suggested the resident be checked by her own physician in two to three days and that she go to her doctor or the emergency room if pain or shortness of breath were getting worse, for persistent coughing, for fever or chills, or for abdominal pain, vomiting, severe weakness or fainting. They suggested she beware of falling again and report to her doctor if she experienced dizziness, severe weakness, inability to get up after a fall, abdominal pain, vomiting, diarrhea, passing black or bloody stools, headache, vision problems, or numbness or weakness in one arm or leg. It was anticipated by all concerned that the resident would only remain in Respondent’s facility for five days, and would only require personal observation as necessary, assistance with her ADLs, monitoring of her pain, and assistance taking her medications. However, the family had selected Respondent’s ALF, in part, because it was near a hospital in case the resident’s condition worsened or an emergency of some kind arose while they were out of town. In addition to the new prescription for Hydrocodone, the resident previously had been prescribed a number of medications unrelated to her fractured ribs. Among these were Lorazepam, Coumadin, Captopril, and Trazodone. Hydrocodone is a controlled substance, as is Lorazepam. The Lorazepam, an anti-anxiety drug like Activan, is a sedative. It had been prescribed to be taken twice a day, morning and evening. The Hydrocodone had been prescribed to be taken “eight hours prn,” or “every eight hours as needed.” Respondent is not a skilled nursing facility, so its personnel cannot legally administer prescription medications. Respondent’s written policy and procedures for facility personnel provide for them to assist residents with self-administration of drugs, including special procedures for assistance with controlled substances. Under these procedures, controlled substances remain under lock and key and are to be listed on a separate drug inventory sheet called a “Controlled Substance Countdown Record” (CSCR), and the actual pills are to be counted before and after each shift. Patty Clair, a Patient Care Advisor at Respondent’s facility, testified that she knew that facility personnel could “assist” a resident in taking his/her medications by bringing the medicine to the resident and placing that resident’s pills on the resident’s hand, but that the resident was responsible for actually moving the pill to his/her mouth. Respondent facility also maintains a Medication Observation Record (MOR), which must be updated immediately each time a resident takes any medication or refuses a medication. Petitioner Agency specifies by rule the information that the MOR must contain. At Respondent’s facility, the Coumadin was incorrectly charted to eliminate the Sunday, April 8, 2007, dosage, and the Hydrocodone was incorrectly transcribed on the MOR as “every eight hours,” instead of “eight hours prn.” Review of the resident's MOR reveals that there is no documentation that the following medications were taken or refused by the resident as prescribed on the respective dates: Coumadin, two tablets on Sunday, April 8, 2007. Captopril, one tablet on Thursday, April 5, 2007, and two tablets on Friday, April 6, 2007. Trazodone, two tablets on Thursday, April 5, 2007, and two tablets on Friday, April 6, 2007. (Stipulated) During the period April 5, through April 10, 2007, the CSCR for Hydrocodone indicates that five tablets were taken from the resident's supply of Hydrocodone, but the MOR only documents self-administration of three tablets. (Stipulated) During the period April 5, 2007, through April 10, 2007, the CSCR for Lorazepam indicates that nine tablets were taken from the resident's supply of Lorazepam. The MOR for that same period documents the self-administration of nine tablets, but does not document self-administration at 8:00 p.m. on April 8, 2007, or 8:00 a.m. on April 9, 2007. It does indicate self-administration on April 10, 2007, at 8:00 a.m. and 8:00 p.m. (Stipulated) Other than the Lorazepam, there is no documentation that the resident self-administered any other medication on the morning of April 10, 2007, which is the day she left the facility. (Stipulated) Patty Clair did not make any writing on the CSCR, even though her name appears on the CSCR for assisting the resident with Lorazepam, on April 6, 7, and 10. (Stipulated) At hearing, Ms. Clair acknowledged assisting the resident with self-administration of her Lorazepam on April 6, 7, and 9, 2007. Ms. Clair initialed the MOR showing that she had helped the resident take her Lorazepam on April 6, 7, and 9, 2007. However, Ms. Clair did not sign the CSCR for April 6, or 7, 2007, even though her name and initials appear on the CSCR for April 6, and her name appears on the CSCR for April 7, 2007. At no time did Ms. Clair give anyone permission to place her initials on the CSCR for the Lorazepam. Ms. Clair did not sign the CSCR for assisting the resident with her Lorazepam on April 10, 2007, at 8:00 a.m. because she did not even work at the facility on April 10, 2007. The resident was discharged from Respondent facility during the morning of April 10, 2007, between 8:30 a.m. and 9:00 a.m. (Stipulated) Because the resident left the facility between 8:30 a.m. and 9:00 a.m. on April 10, 2007, it would have been impossible for the resident to have self-administered the Lorazepam at 8:00 p.m. that day, as was indicated on the CSCR. Also, by that hour, she had been hospitalized. See, infra. Christine Erick, the facility’s resident care coordinator, testified that because the CSCR sheet was not consistent with the actual countdown of the medication, she went back to the MOR to find out who had assisted the resident with her medication, and finding it had been Patty Clair, signed Ms. Clair’s name on the CSCR, with her own initials. Her actions in this regard were contrary to the facility’s record- keeping procedure. Ms. Erick speculated that the dates apparently got “messed up” so that the resident had actually received her last Lorazepam at the facility on April 9, 2007, at 8:00 p.m. Mr. Booker, Agency surveyor and expert nurse, conceded that one explanation that fits with the number of missing Lorazepam tablets (nine), and the number of signed self-administrations of Lorazepam (nine), is that the resident got all her Lorazepam doses but the wrong dates went on the records. He further stated that because the two types of records did not match, no one can be sure what happened. With regard to the Lorazepam, he testified that there were no more missing doses than the doses which were indicated to have been given, and that the doses which were indicated to have been given to the resident to self- administer were in accordance with her prescription. According to Mr. Brooker, all that can be said, based on Respondent facility’s records for Hydrocodone is that something was not given but not that too much was given. The facility’s written record in no way indicated an overdose of Hydrocodone. It is Respondent facility’s protocol that if a resident falls, the incident must be documented and the facility administrator, the resident’s doctor (health care provider), and the resident’s family must be notified. A “follow-up” document is also required to be made out 24 hours later. Respondent’s protocol concerning any injury to a patient is similar, and if the fall/other injury is severe enough, the facility personnel must call 911 for medical aid and transport of the resident to a hospital. There is no reason for facility employees to fail to report a resident’s fall. This facility had all it needed to contact this resident's doctor. It was not established that the resident ever fell in Respondent’s facility. However, on the morning of Sunday, April 8, 2007, the resident was having difficulty walking. She was unsteady on her feet and complained of pain consistent with what the facility knew about her fractured ribs, that from her admission she had occasionally complained of discomfort or pain on her right side. (See Finding of Fact 13). She had decreased gait and balance and was brought to the facility’s dining room for breakfast in a wheelchair. These observations were recorded in the Observation Log by "C.E," Ms. Erick. On April 8, 2007, the resident ate only twenty-five per cent of her breakfast, but that was not unusual. There is no discernable pattern for her consumption of food while in the facility.3/ There is no evidence that the resident lost weight in Respondent’s facility. On April 8, 2007, Ms. Erick telephoned the resident’s daughter in Key West and notified her that her mother had suffered a change of ambulation and was having difficulty walking, with decreased gait and balance. Further content, duration, and sequence of the exchange during this telephone call are in dispute, particularly as to whether Ms. Erik told the daughter that the resident had right hip pain or informed her about the use of a wheelchair, and whether the daughter instructed the facility to take the resident to a hospital if necessary, but it is undisputed that ultimately, Ms. Erick suggested to the daughter, and the daughter agreed, that they give the pain medication, which the Observation Log states had been self-administered at breakfast-time, a chance to work and talk later in the day. The daughter did not request, and Ms. Erick did not offer, to put the resident on the phone at the time of this initial phone call so that the daughter could get the resident’s assessment of the situation. However, Ms. Erick and the daughter concur that the daughter called back that evening to inquire about her mother, and that during the daughter’s return phone call, Ms. Erick told the daughter that the resident had no current complaints of pain and the daughter said she would pick her mother up on Tuesday. On April 8, 2007, Ms. Erick initialed a single long comment in the Observation Log covering Findings of Fact 39 and 40. Following Ms. Erick's April 8, 2007, Observation Log entry, there is a later, April 8, 2007, entry in a different handwriting, signed by someone else. The entry includes that the resident complained of slight pain in the rib area and stated that she was a little stiff. It further states that the resident ate 75 per cent of her meal and received nourishment via a snack; that the daughter was told of pain; that the daughter stated she would be in “tomorrow” to pick up her mother, and that pain meds were again provided to the resident. Whether the person who signed this second notation for April 8, 2007, actually spoke with the daughter is unclear, because that writer did not testify, and both Ms. Erick and the daughter are clear that only two telephone conversations took place between them, but this later April 8, 2007, notation in the Observation Log does confirm that April 8, 2007, is the only day that the resident ingested two "pain" tablets of Hydrocodone. Based upon the evidence as a whole, including the candor, demeanor, and reasonableness of the respective testimony of Ms. Erick and the daughter, and particularly the contemporaneous Observation Log in its entirety, it is not credible that pain specifically in the right hip was complained- of by the resident on April 8. Also, the next day, April 9, 2007, the Observation Log shows a notation of no complaints of pain from the resident, only stiffness, and this notation is also signed by a staff member other than Ms. Erick. In summary, the Observation Log shows that "Hydrocodone prn for pain" is the pain medication, and that on April 5, one pain pill was given; on April 7, one pain pill was given; and on April 8, two pain pills were given. The CSCR shows two, and the MOR shows only one, Hydrocodone pill was given on April 8, 2007. Respondent did not contact the resident's health care provider during the period beginning when she entered the facility on April 5, 2007, and ending when she was discharged from the Crystal Gem facility on April 10, 2007. (Stipulated) Breakfast at the facility is served in the dining room at approximately 7:00 a.m. Residents are dressed before they go to the dining room, but the Observation Log for April 10, 2007, contains no entry concerning the resident's breakfast. On April 10, 2007, when the daughter arrived between 8:30 and 9:00 a.m., the resident was lying on her bed, fully clothed. Ms. Erick assisted the resident into a wheelchair, and the daughter took the resident to her car, later returning the wheelchair to the facility. The daughter was not assisted in this endeavor by any facility employee. The daughter testified that someone in the parking lot assisted her with getting the resident into her car. She described the resident as pale, weak, unresponsive, and confused during this period. Facility protocol calls for Ms. Erick to count out each of a resident’s medications with the family member who signs out the resident and to have the family member sign for the pills being returned. Although neither Ms. Erick nor the daughter has any memory of counting out the pills, there is a notation in the Observation Log by another staff person for that day, stating that medications were given to the daughter. Because of this contemporaneous notation, and because the daughter signed for the pills returned to her at the bottom of the CSCR, it is more likely than not that the pills were counted out by another staff member and the daughter, than that they were not counted out at all and were already bagged in the resident’s luggage, as testified-to by the daughter. This CSCR sign-out sheet shows that from April 5-10, 2007, five Hydrocodone tablets were used and nine Lorazepam tablets were used. (See Findings of Fact 25-26.) On April 10, 2007, during the 25-minute drive home from Respondent’s facility, the daughter was unable to converse with the resident, who was moaning and unresponsive. Upon arriving at the home, the daughter realized that she could not lift or carry the resident to the house. At approximately 11:00 a.m. April 10, 2007, the daughter appeared at the door of her next door neighbor’s home, asking for assistance. The neighbor is a registered nurse. The neighbor went with the daughter and found the resident sitting on the walkway between the car and the family home, several feet from the car. The resident was sleepy, difficult to move, and was unable to stand. The women moved the resident into her bedroom inside the house, using a rolling computer chair. The resident was put to bed. She was sleepy, but not comatose.4/ The daughter denied administering any medication to the resident that day. The nurse/neighbor stayed for about 30 minutes, comforting the daughter, and then left for work. She advised the daughter to wake the resident in about an hour, get her up and to the bathroom, and give her something to drink so as to prevent dehydration. At 1:49 p.m. on April 10, 2007, the daughter made a 911 call. A highly trained and skilled paramedic, who arrived by ambulance at 2:01 p.m., testified that the resident had no dehydration, had normal blood sugar, and indicated no pain, but her oxygen level was low. The resident was sleepy, but responsive to speech. The paramedic rated the resident as being 14 on the Glasgow coma scale, 15 being normal. Upon receiving information concerning the resident’s medications, it appeared to the paramedic that either Hydrocodone or Lorezepam was causing the resident to be over- sedated. The resident’s oxygen level began to drop en route to the hospital. Narcon is a drug used to counteract narcotics. Lorezapam does not respond to Narcon, but Hydrocodone does. The paramedic administered one Narcon “push,” without much result, at 2:29 p.m. A second Narcon “push” was administered at 2:37 p.m. At that point, the resident became alert and her "stats" went up. At no point did the paramedic ever conclude that the resident’s situation was “life threatening.” The resident was delivered to the hospital emergency room 40 minutes after leaving the family home. Hospital records for April 10, 2007, at 5:10 p.m., show the resident as "normotensive" (with normal blood pressure),5/ dehydrated, and with a right hip fracture. They further show that her blood had an abnormal level of Lorazepam by 510 nanograms per milliliter, a very low abnormality. The lab did not rate this Lorazepam level as "critical" or "high, but listed it only as "abnormal." Subsequent to surgery to correct the broken hip, the resident died at an unspecified date. On or about October 31-November 1, 2007, the daughter notified Petitioner Agency of suspicions she had concerning her mother’s care at Respondent facility April 5-10, 2007. The Agency sent Mr. Brooker to investigate. Mr. Brooker classified Respondent’s failure to notify the resident’s health care provider of her change of condition on April 8, 2007, as a Class II violation, because hospital records on April 10, 2007, showed a fractured hip. He classified the facility's record-keeping inaccuracies as a Class II violation, because Hydrocodone and Lorazepam were involved; because abnormal levels of Lorazepam were found in the resident’s blood on April 10, 2007; and because of the serious harm drugs such as Hydrocodone and Lorazepam can cause. His assessment is not contrary to the Agency’s charging pattern statewide.
Recommendation Based on the foregoing Findings of Facts and Conclusions of Law, it is RECOMMENDED that the Agency for Health Care Administration enter a final order finding Respondent not guilty of a Class II deficiency under Count I of the Administrative Complaint and not guilty of a Class II deficiency under Count II of the Administrative Complaint. DONE AND ENTERED this 31st day of October, 2008, in Tallahassee, Leon County, Florida. S ELLA JANE P. DAVIS 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 31st day of October, 2008.
Findings Of Fact Respondent, Gregory Burgess Stone, is a licensed practical nurse holding license number 0463451. Respondent was so licensed at all times relevant to this proceeding. Respondent was employed at Orlando Lutheran Towers Health Care Center, 300 East Church Street, Orlando, Florida, as a practical nurse at all times material hereto. During April, 1982, Respondent acted as the full-time medicine nurse on the 7:00 a.m. through 3:00 p.m. nursing shift at Orlando Lutheran Towers. Orlando Lutheran Towers utilizes the Unidose system of medication administration. The individual who administers the medication is required only to remove the appropriate dosage from the Unidose card which may contain from thirty to sixty doses of medication and thereafter record the administration of the medication on a medication administration record by inserting his initials under the appropriate date on the medication administration record format. Each patient at Orlando Lutheran Towers is assigned a Unidose card for each medication he may require. The patient's name and other pertinent information appear on a label placed on the front of the Unidose card. Respondent was intermittently relieved from duty in April by Gloria Underhill, another nurse-employee of Orlando Lutheran Towers. Underhill worked in place of Respondent on April 8, and the Respondent thereafter worked the intervening period from April 9 through April 12. Underhill returned to work in place of Respondent again on April 13, and in the course of administering medications, she observed that certain prescribed medications had not been administered between April 9 and April 13. Underhill ascertained this information because of the procedure she had previously followed. It was Underhill's general practice to place her initials not only on the medication administration record but also on the Unidose card next to the particular unit of medication she intended to administer. By comparing her initials with the physical presence of the succeeding units of medication in the Unidose card, she determined that the Respondent had apparently failed to administer medication to the following patients: PATIENT MEDICATION UNITS NOT RECEIVED 1. Lowe DDS 100 milligrams 4 2. Doze Corgard 40 milligrams 4 3. Miller TAM/LL 3 The medication administration record, however, indicated by the placement of the Respondent's initials that the foregoing medications had been received. Respondent speculated that he may have administered the medication by utilizing doses not taken by other patients. This possibility was not supported by the evidence and is rejected. Underhill's findings were given to the Director of Nursing and the Administrator of Orlando Lutheran Towers, who thereafter confronted Respondent with the Unidose card discrepancies. Respondent did not offer any explanation for the discrepancies and was therefore discharged from employment at Orlando Lutheran Towers.
Recommendation Based on the foregoing, it is RECOMMENDED: That Petitioner enter a final order finding Respondent guilty of the violations of law charged in the Administrative Complaint and placing his license in a probationary status for two years. DONE and ORDERED this 18th day of March, 1983, in Tallahassee, Florida. R. T. CARPENTER, Hearing Officer Division of Administrative Hearings The Oakland Building 2009 Apalachee Parkway Tallahassee, Florida 32301 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 18th day of March, 1983. COPIES FURNISHED: W. Douglas Moody, Esquire 119 North Monroe Street Tallahassee, Florida 32301 James M. Nicholas, Esquire 170 East Washington Street Orlando, Florida 32801 Helen P. Keefe, Executive Director Board of Nursing Department of Professional Regulation Room 504, 111 East Coastline Drive Jacksonville, Florida 32202 Fred Roche, Secretary Department of Professional Regulation 130 North Monroe Street Tallahassee, Florida 32301
The Issue Whether Respondent committed the violations alleged in the Amended Administrative Complaint and, if so, what penalty should be imposed.
Findings Of Fact AHCA is the agency responsible for the licensing and regulation of assisted living facilities in Florida pursuant to Chapter 400, Florida Statutes. At all times material hereto, Northpointe was licensed as an assisted living facility with a capacity of 100 beds. Northpointe is located in Pensacola, Florida. Count I As the result of a complaint received by AHCA, Norma Endress, a registered nurse and agency surveyor employed by AHCA, conducted a survey inspection of Northpointe on March 1 and 2, 2002. According to Nurse Endress, the nature of the complaint was an allegation regarding failure to prevent falls. Upon arriving at Northpointe, Ms. Endress spoke with Rochelle Pitt, a Licensed Practical Nurse who is Director of Nursing at Northpointe, made a quick tour of the facility and then asked for the records of five residents. These records included those of Resident 1 and four others chosen randomly. Included within Resident 1's records was an Outcome Planning Discharge Sheet (discharge sheet) from Sacred Heart Hospital dated January 31, 2002. The discharge sheet noted that Resident 1 had a wound on his left heel. The discharge sheet included a section entitled "Post Discharge Medical Appointments" which included the following hand written notation: "Dr Matthew Ethridge (Podiatrist) (illegible telephone number). Date + time to be arranged within the week by daughter." The discharge sheet also included a section entitled "Medications Dose Frequency" which contained the following hand written notation: "Resume pre-hospital meds. Clean and dress left heel (illegible) everyday with antibiotic ointment and dress with gauze." Also included within Resident 1's records was another document from Sacred Heart Hospital which indicates that Resident 1 subsequently was treated in the Emergency Room on February 2, 2002. This document includes a section entitled "Triage," which indicates that Resident 1 was seen in the Emergency Room because of a fall and that Resident 1's chest hurt. The section of the February 2, 2002, Emergency Room document entitled "Physical Exam" indicates that Resident 1 was awake and alert and was accompanied by his daughter. This section also includes the following: "EXTREMITIES: no clubbing, cyanosis, WITH2+ edema, perpipheral pulses intact, motor and sensation intact. BANDAGE ON FOOT NOT CHANGED AS HOME HEALTH NURSING CHANGING REGULARLY." (emphasis in original) During the survey inspection, Nurse Endress also reviewed Resident 1's medication record. According to Nurse Endress, the medication record did not reference the discharge instructions of the physician from the January 31, 2002, discharge from the hospital.1/ Also included in Resident 1's records was a fax cover sheet dated February 1, 2002, from Rochelle Pitt of Northpointe to Dr. Retzloff. The fax cover sheet contained the following hand written notation: "Returned from hospital 1-31-02, needs new health assessment (with) orders for home health to open area L heel. (see discharge instructions) Thanks, Rochelle Pitt." According to Nurse Endress, there was nothing in Resident 1's medication administration record or medical chart to reflect the physician's discharge instructions of January 31, 2002 nor to indicate that Resident 1 received any treatment to his left foot after his discharge from the hospital on January 31, 2002. Mr. M. H. Mikhchi is the administrator of Northpointe. According to Mr. Mikhchi, the type of license held by Respondent does not permit it to do the dressing changes on Resident 1's foot referenced in the doctor's hospital discharge instructions. That is, Respondent asserts that it holds a standard license, not a mental health license or a limited nursing license. According to Mr. Mikhchi, Respondent received a call from the hospital prior to Resident 1's discharge on Thursday, January 31, 2002, informing them that Resident 1 was being discharged. The following day, Friday, February 1, 2002, Nurse Pitt sent a fax to Dr. Retzloff, requesting a new health assessment with orders for home health care to treat Resident 1's heel. The time of day that this request was faxed is not reflected on the fax cover sheet, although Mr. Mikhchi indicated that it was Friday afternoon. The request was necessary because Resident 1's insurance required a physician's order for home health services. According to Mr. Mikhchi, Respondent did not hear back from Dr. Retzloff's office on Friday, February 1, 2002. As a result, the weekend passed without Resident 1 receiving home health care for his heel wound. Mr. Mikhchi acknowledges that Nurse Pitt viewed the heel wound over the weekend although the record is unclear as to whether or not she changed the dressing or applied ointment. Nurse Pitt's actions in this regard were not recorded in Resident 1's record because of the limitation of Respondent's license. Upon Resident 1's return to the facility, Nurse Pitt noted that Resident 1's discharge order stated that Resident 1's daughter would set up an appointment with Dr. Ethridge. As far as Nurse Pitt or Respondent knew, Resident 1's daughter had not set up an appointment with the doctor as of Monday, February 4, 2002. Accordingly, Nurse Pitt called the office of Dr. Ethridge, a podiatrist, on Monday, February 4, 2002, to set up an appointment which was then scheduled for the following day. Count II Shawn Bolander is a registered nurse and a surveyor for AHCA. According to Nurse Bolander, she went to Respondent's facility on April 5, 2002, to conduct a survey visit as a follow-up to a complaint investigation. However, the record contains no evidence as to the nature or subject matter of the complaint investigation to which this was a follow-up survey visit. There is nothing in Nurse Bolander's testimony to indicate that her visit of April 5, 2002, was related in any way to the events discussed above regarding Count 1 or Resident 1. Upon arriving, Nurse Bolander took a tour of the facility and requested a list of residents to select a sample of records for chart review. She reviewed the records of Resident 22/ and found that there was a missing page to Resident 2's medication administration record. She determined that there was a missing page by comparing the physician's orders to the medication administration record for the month of April. That is, Resident 2's resident health assessment mentioned two medications that were not found on Resident 2's medication administration record. Upon discovering that some medications were not listed on the medication administration record, Nurse Bolander spoke to Nurse Pitt. Nurse Bolander requested that Nurse Pitt recopy the second page of Resident 2's medication administration record and provide her with a copy of it prior to Nurse Bolander's departure from Respondent's facility. Nurse Pitt did provide Nurse Bolander with a second page to Resident 2's medication administration record prior to Nurse Bolander's departure from the facility on April 5, 2002. At the top of the second page of the medication administration record appears the following hand written notations: "Re-written 4-5-02 2:15pm RP." This was followed by a notation made by Nurse Bolander which read, "Received 4/5/02 SB @2:35." Page two of Resident 2's medication administration record listed six medications, three of which were designated "PRN." Based upon her review of the medication administration record, Nurse Bolander determined that there was no evidence that Resident 2 actually received any of the medications listed on page two from April 1, 2002 to April 5, 2002. There is nothing in the record to support the allegation in Count II that Respondent's alleged failure to maintain an up to date medication observation record is a repeat violation.
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 Amended Administrative Complaint issued against Respondent, Northpointe Retirement Community. DONE AND ENTERED this 8th day of November, 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 8th day of November, 2002.
