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.
Findings Of Fact The Respondent is a registered nurse who began her employment at South Lake Memorial Hospital on August 29, 1977, and was terminated on April 23, 1980. During her employment, the Respondent received four poor evaluations and/or warnings for her nursing practice. The first warning occurred on August 1, 1979. This warning involved allegations of poor nursing performance by the Respondent. These allegations included the Respondent leaving her unit, failing to properly organize her work, failing to properly restrain a patient, wasting time by running too many EGG strips instead of performing her assigned functions, failing to take vital signs timely when coming onto shift, becoming hostile with the Director of Nursing, and failing to obey the direct order of the Director of Nursing to leave the hospital and go home after an argument on July 12, 1979. Although there was no direct evidence as to most of the allegations, the Respondent admitted to late charting, failing to timely take vital signs, spending time working with ECG strips, and failing to obey a direct order to-go home given by the Director of Nursing. The next evaluation occurred on November 26, 1979. The deficiencies in Respondent's practice as alleged by the Director of Nursing were that the Respondent gave a patient whole blood instead of packed cells as ordered by the physician, failed to verify an error in transcription by the ward clerk which resulted in a patient's x-rays being delayed for a day, and improperly charting when the Respondent noted on the nursing notes that at 9:00 p.m. there was no significant change in a patient's condition, when in fact the patient had left the hospital at 8:30 p.m. The lack of direct evidence of these allegations was compensated for by the Respondent's admissions as she testified concerning the circumstances surrounding why the incidents occurred. The third warning occurred on March 19, 1980. The allegations in the warning concerned the Respondent having shouted at a supervisor, abandoning her patients, allowing two I.V.s to run dry, failing to carry out a doctor's orders, and failing to chart. Again, there was no direct evidence of the allegations, however, the Respondent admitted that she left her duty station because of sickness prior to relief arriving in the unit, failed to properly follow doctor's orders, and failed to chart for the time she was present in the unit prior to her reporting to the emergency room. The fourth and final warning, which resulted in termination, occurred on April 23, 1980. The allegations by the Director of Nursing were that the Respondent hung one-fourth percent normal saline solution rather than the one- half percent normal saline solution ordered by the physician, and that the Respondent failed to administer the 5:00 p.m. medication. Again, the allegations were admitted by the Respondent as she attempted to explain why they occurred. The Director of Nursing testified that during each of these warnings, the Respondent's attitude was that she had done nothing wrong and, therefore, could not improve on her performance. The testimony of the Department's nurse investigator was to the effect that the Respondent's actions failed to meet the minimal standard of acceptable and prevailing nursing practice. The investigator also testified that, in her opinion, a nurse with Respondent's poor attitude could be extremely dangerous in a hospital setting. After many years of difficult and stressful work, many nurses suffer from what is commonly referred to as "burn out" and are no longer useful, and can be dangerous in a high stress area of nursing. Respondent testified in her own behalf and offered an explanation for each allegation presented by Petitioner. Respondent testified that relative to the first warning, even though she only had two patients, she did not have adequate time to do her charting during her shift and, therefore, had to stay two hours late. Respondent further testified that on one occasion she had not timely taken her vital signs because the Director of Nursing had delayed her with a needless confrontation. Respondent testified that she did not leave the facility as ordered on August 12, 1979, because she was afraid that she would be abandoning her patients, and could lose her vacation and sick leave benefits. With respect to the November 26, 1979 evaluation, the Respondent testified that she gave whole blood instead of packed cells because the whole blood was incorrectly labeled as packed cells. Respondent further testified that she became aware of the error after the solution had infused, and that had she looked at the solution earlier she would have been able to see that it was an incorrect blood product, and would have been able to correct the problem. As to the incorrect transcription resulting in a patient's x-rays being delayed, the Respondent stated that it was the ward clerk's responsibility, not hers, to transcribe the doctor's orders. With respect to the 9:00 p.m. nursing notes when the patient had left the facility at 8:30 p.m., the Respondent's response was that she had been aware that the patient was gone, but was summarizing the patient's condition during the entire shift up to the point the patient left. Respondent acknowledge that the nursing notes may have been misleading. As to thee warning of termination on March 19, 1980, the Respondent admitted leaving her unit prior to relief arriving. Her explanation gas that she had been attempting for one hour to get assistance, to no avail. Upon questioning, she admitted that she was-only "a little dizzy" and had diarrhea. On that day she did not chart any nursing care given by her while on duty. The Respondent was caring for twelve patients at that time. With respect to the April 23, 1980 termination, Respondent admitted that she hung the incorrect percentage saline solution, but that she did so because a prior nurse obtained the incorrect solution from a supply room. The Respondent then also admitted failing to give out the 5:00 p.m. medication as ordered, but stated the reason for her failure to administer the medication was her inability to obtain help from her supervisor which was necessary because she was overworked. Respondent also testified that during this time period, she went on rounds with a doctor, and also went to dinner. The Respondent testified that she felt she was a good and qualified nurse. Respondent also testified that she had been fired previously from Leesburg General Hospital. The Respondent believes her attitude to be good and indicated that the hospital was overreacting to a few isolated incidents.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That the Respondent's license to practice nursing in the State of Florida, license number 39108-2, be suspended indefinitely. If the Respondent seeks reinstatement, it will be her responsibility to undergo counseling with a psychologist or psychiatrist, for an in-depth evaluation and treatment, the results of which shall be submitted to the Board of Nursing if and when the Respondent wishes to apply for reinstatement of her nursing license. If the Respondent applies for reinstatement of her license, it shall be her responsibility to demonstrate to the Board that she is able to engage in the practice of nursing in a safe, professional, proficient and legal manner. This demonstration shall include but not be limited to a report by her psychologist or psychiatrist, along with a recommendation from him that she be reinstated to the practice of nursing. 1/ DONE and ORDERED this 8th day of January, 1982, in Tallahassee, Florida. SHARYN L. SMITH, 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 8th day of January, 1982.
The Issue The issue for determination is whether Respondent committed the offenses set forth in the Administrative Complaint and, if so, what action should be taken.
Findings Of Fact Sunrise operates as a skilled nursing facility at 4800 Nob Hill Road in the city of Sunrise, Florida. Sunrise is licensed by the State of Florida pursuant Chapter 400, Part II, Florida Statutes. Sunrise has 325 beds. At all times material hereto, Sunrise had approximately 275 to 285 residents. AHCA conducted a Standard survey of Sunrise on April 14 through 17, 2003, to determine if Sunrise was "in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid programs."2 AHCA determined that Sunrise was not in "substantial compliance" with the federal requirements in that, material hereto, Class III deficiencies had occurred, citing (1) Tag F-332, having a medication error rate of five percent or greater and (2) Tag F- 333, having significant medication errors. Further, the following Florida Administrative Code Rules were cited for the Class III deficiencies: Tag F-332, 59A-4.112(1), 59A-4.107(5), and 59A-4.1288; and Tag F-333, 59A- 4.1288. As to Tag F-332, two medication errors were found. Resident PR received Sorbitol Solution without a physician's order, instead of Lactulose, as ordered by the physician. Resident GW did not receive Reglan prior to eating breakfast as ordered by the physician. On the survey, Resident No. 31 is Resident PR and Resident No. 32 is Resident GW. As to Tag F-333, two medication errors were found. Resident MZ received Potassium Chloride Elixir in undiluted form or without water, contrary to the instructions on the medication. Resident GW did not have her Nitroglycerin Patch removed the prior evening, as ordered by the physician. On the survey, Resident No. 33 is Resident MZ. Moreover, AHCA determined that the medication errors, involving Potassium Chloride and Nitroglycerin, were significant medication errors because Potassium Chloride and Nitroglycerin are medications affecting the cardiovascular system. Significant medication error is defined by the Guidance to Surveyors - Long Term Care Facilities, in pertinent part, as follows: [O]ne which causes the resident discomfort or jeopardizes his or her health and safety. . . .Discomfort may be a subjective or relative term used in different ways depending on the individual situation. The evidence presented was insufficient to show that an individual Resident experienced discomfort due to the medication errors or to show that the medication errors had the potential to cause an individual Resident discomfort. The evidence presented was insufficient to show that the medication errors jeopardized an individual Resident's health and safety. Nevertheless, the medication errors had the potential to jeopardize the health and safety of the Residents. Also, material hereto, Sunrise was not cited by AHCA for failure to follow physicians' orders. The percentage of errors is calculated by dividing the number of medication errors by the total number of medication opportunities. In the survey of Sunrise, AHCA's surveyors used the "Medication Pass Worksheet" (MPW). If one or more errors are found, the MPW provides that another 20 to 25 opportunities should be observed. Four medication errors were observed. Sixty-two medication opportunities were observed, which included the additional opportunities observed by the surveyors. The percentage of medication errors was 6.45 percent. AHCA required Sunrise to correct the deficiencies cited by May 17, 2003. Further, a Plan of Correction (POC) was required to be submitted by Sunrise to correct the deficiencies cited. Sunrise submitted a POC. By certified letter dated, April 25, 2003, AHCA notified Sunrise, among other things, that the survey found that Sunrise was not in substantial compliance; that a POC was required to be submitted by a time certain; that remedies would be recommended if substantial compliance was not achieved by May 17, 2003; that the recommended remedies would include a mandatory denial of payment for new admissions being imposed on July 17, 2003, if substantial compliance was not achieved by that time; and that AHCA may accept the POC as Sunrise's allegation of compliance until substantiated by a revisit or other means. On May 22, 2003, a re-survey was conducted by AHCA. AHCA determined that Sunrise was not in substantial compliance with the federal requirements. Material hereto, AHCA found Class III deficiencies during the survey of May 22, 2003, citing (1) Tag 281, providing or arranging services that fail to meet professional standards of quality, including failing to follow physician's orders and having significant medication errors, and (2) Tag F-332, having a medication error rate of five percent or greater. Further, the following Florida Administrative Code Rules were cited for the Class III deficiencies: Tag F-281 and Tag F-332, 59A-4.112(1), 59A-4.107(5), and 59A-4.1288. As to Tag F-281, pertinent hereto, Resident BC was administered five medications prescribed for Resident HF. The medications were Provera, Prednisone, Claritin, Multivitamin with Mineral, and Flomax. On the survey, Resident No. 2 is Resident BC and Resident No. 1 is Resident HF. Also, as to Tag F-281, pertinent hereto, Resident RP was administered Thera M, a multiple vitamin with minerals, when her prescription was for Theragram, a vitamin only. On the survey, Resident No. 19 is Resident RP. Further, as to Tag F-281, pertinent hereto, Sunrise was cited for failure to follow physicians' orders. As to Tag F-332, the same method for the calculation of percentage errors was used. Six medication errors were observed. Fifty medication opportunities were observed, which included the additional opportunities observed. The percentage of medication errors was 12 percent. AHCA required Sunrise to correct the deficiencies cited by June 22, 2003. The evidence presented was insufficient to show that an individual Resident experienced discomfort due to the medication errors. However, the medication errors had the potential to cause the Residents to experience discomfort. The evidence presented was insufficient to show that the medication errors jeopardized an individual Resident's health and safety. Nevertheless, the medication errors had the potential to jeopardize the health and safety of the Residents. By certified letter dated May 30, 2003, AHCA notified Sunrise, among other things, that, based on the survey conducted on May 22, 2003, Sunrise was not in substantial compliance due to Tag F-281 and Tag F-332 being found; that the investigative survey was still ongoing; and that the recommendation would be made to impose the same remedies recommended in the letter dated April 25, 2003. By letter dated July 23, 2003, AHCA notified Sunrise, among other things, that, as a result of a second follow-up visit completed on July 14, 2003, Sunrise was in substantial compliance as of July 15, 2003. Sunrise was issued a conditional license by AHCA effective May 22, 2003 and expiring September 30, 2003. At the expiration of the conditional license, Sunrise was issued a standard license.
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: Upholding the issuance of a conditional license to Richmond Health Care, Inc., d/b/a Sunrise Health & Rehabilitation Center. Imposing a fine of $1,000 upon Richmond Health Care, Inc., d/b/a Sunrise Health & Rehabilitation Center. DONE AND ENTERED this 17th day of May 2004, in Tallahassee, Leon County, Florida. S ERROL H. POWELL 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 17th day of May, 2004.
The Issue Whether Petitioner's license should be changed from Standard to Conditional and/or disciplined.
Findings Of Fact Brynwood is a 97-bed licensed nursing home located in Monticello, Florida. On April 23 through 25, 2002, AHCA conducted a survey of Brynwood. AHCA asserted two "tag" deficiencies involving Resident No. 4. The deficiencies involved Tag F-309 and Tag F-314. Tag F 309 represents 42 C.F.R. Section 483.25, which states that, Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Tag F-314 represents 42 C.F.R. Section 483.25(c), which states that, Based on the comprehensive assessment of a resident, the facility must ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless . . . they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing. . . . Resident No. 4 was admitted to Brynwood on September 21, 2001. Resident No. 4 had congestive heart failure, arthropathy, anxiety, and renal failure, among other diagnoses. Resident No. 4 also had severe arthritis, was bed- bound, and a hospice patient. Her medical condition caused her to be in pain. The investigator observed Resident No. 4 on April 23, 2002, at 3:30 p.m., 4:14 p.m., and 5:15 p.m.; on April 24 at 2:30 p.m.; and on April 25 at 8:30 a.m. The investigator observed a dressing change to the pressure sore during which resident No. 4 was moaning and groaning. Around 11:00 a.m. on April 23, the investigator's initial observations were that Resident No. 4 was lying in bed on her back with her mouth opened. She was very thin and was moaning and groaning. During the investigator's initial observations, she was touring with one of the staff nurses and was able to ask the nurse some questions about Resident No. 4's condition and current behavior. The investigator also spoke with the director of nursing regarding Resident No. 4. With regard to Tag F-309, the testimony of the investigator was essentially that the tag was violated because she believed not enough was being done to control the resident’s pain. The director of nursing informed the investigator that Resident No. 4 had some pressure sores and a lot of arthritis, the most severe of which was in her knees and back. Resident No. 4 was prescribed some regular pain medications, as well as pain medications on an as needed basis. The regular pain medication was Oxycontin two times per day with Vicodin, as needed. Oxycontin is a morphine derivative and a very strong narcotic. Vicodin is also a strong narcotic, but not as powerful as Oxycontin. Resident No. 4 had received the Oxycontin as prescribed. In fact, a number of different pain medications had been tried with Resident No. 4 while she was at Brynwood in order to find the most appropriate and effective relief. There was a care plan for Resident No. 4's pain. The investigator testified that during the months of March and April, Vicodin was only given a few times. In April, up until the date of the survey, Vicodin was only given six times. However, the investigator only reviewed the Medication Administration Record (MAR) to determine the amount of medication given to Resident No. 4. She did not review any other medication records. The administration of a narcotic medication can be noted in at least three different places in the resident’s chart: the nursing notes, the MAR, and the controlled drug sheets. As indicated, the investigator checked only the MAR in reaching her conclusion that Vicodin had been given only six times in April. The controlled drug sheets, however, noted that Vicodin was given 18 times in April prior to the conclusion of the survey. While it might have been a documentation error not to note these instances on the MAR as well, the information on the controlled drug sheet is also supported by nursing notes and demonstrates that the pain medication was given. Additionally, in Resident No. 4's case, moaning was not always a sign of pain. The resident moaned anytime she was disturbed--if her covers were moved or her tube feeding was started, or her undergarments were changed. Monitoring of Resident No. 4's condition is repeatedly documented in the nurses’ notes. Other measures were taken by hospice caregivers to provide relief to Resident No. 4, such as playing music. Contrary to suggestion by the investigator that other approaches, such as applying heat or acupressure should have been tried, these methods would not be appropriate for a resident such as Resident No. 4 who has an adverse reaction to any touch or disturbance. Resident No. 4’s family also had expressed concern about the resident being overmedicated, and staff were therefore attuned to this issue and tried to balance the need for pain relief with the possibility of overmedication. The investigator conceded that overmedication could also result in a failure to "maintain the highest practicable" level of functioning. Such overmedication concerns were particularly important given the fact that Resident No. 4 was already taking two very powerful narcotic pain medications. The investigator testified that she cited Tag F-309 as a Class II deficiency because not doing enough to control the resident's pain compromised the resident's ability to maintain, or reach her highest practical level. However, there was no evidence by any medical expert that any further medication or intervention was necessary or appropriate to control Resident No. 4's pain, given the pain medication being taken by Resident No. 4 and her resistance to being touched. Therefore, no violation of Tag F-309 was established by the evidence. With regard to Tag F-314, the investigator’s concerns revolved around an asserted delay in a full dietary assessment upon the resident’s admission on September 21, 2001, and what the investigator perceived to be inadequate monitoring of a pressure sore which she believed developed on September 24, 2001, and became a Stage IV pressure sore by the time of the survey. An assessment of the resident's skin condition was conducted at admission. At the time, the resident received a score of 13, indicating the resident as being a moderate risk for developing pressure sores. Also, an assessment of the resident's dietary needs was done by the dietary manager. Resident no. 4 was placed on a regular diet. At the time, the dietary manager did not have the resident’s height, but lack of this detail was harmless, as the resident was a very tiny and thin person. A regular diet is designed to provide adequate nutrition to persons of a typical size, and smaller persons generally have smaller nutritional requirements. The investigator suggested that because the resident lost approximately three and half pounds, she was undernourished. However, the resident was taking a diuretic which could cause a weight loss of this magnitude. The weight loss did not continue. Given these facts the evidence did not demonstrate that Resident No. 4 was undernourished or that Tag F-314 was violated by the facility by any delay in signing the resident's dietary plan. On September 24, a nurse noted an open area on the resident’s coccyx. The open area was not called a pressure sore and there is no substantial evidence that the open area was a pressure sore. Appropriate treatment of the area was begun immediately. Although the investigator testified that she did not see evidence of the progress of the sore, the treatment sheets clearly reflect that treatments of the open area were given. The last treatment occurred on October 12, 2001, because the area had healed. There was no evidence that the resident's regular diet was insufficient for Resident No. 4 or that the diet contributed to the development of any pressure sore. There was no indication of any other sores or open areas on Resident No. 4 until March, when Resident No. 4 went to the hospital on two occasions. Upon her readmission to Brynwood, it was noted that she had a pressure sore acquired in the hospital. Appropriate treatment was being given to the pressure sore by Brynwood. The wound worsened to a Stage IV pressure sore during her second hospital admission, as documented in the clinical records. The investigator’s concern about Resident No. 4's pressure sore appeared based on the misunderstanding that the pressure sore she had at the time of survey first occurred on September 24 and had existed and deteriorated since that time. Apparently, the investigator overlooked treatment records for the open area and the pressure sore in her review. These records clearly demonstrate that the wound which the resident had at the time of survey was not acquired while at Brynwood and was being treated appropriately by Brynwood. It is standard practice to turn a resident every two hours to prevent development of pressure sores. The investigator felt staff at Brynwood were not turning Resident No. 4 a sufficient number of times because she saw her on her back. The times which the investigator indicated the resident was on her back were: 12:10, 1:00, 4:15, and 5:15 on April 23; 8:30 and 2:30 on April 24; and 8:30 on April 25. These observed instances do not demonstrate a failure to turn and position the resident every two hours, as there was no continuous observation over a two-hour time period. Additionally, there was evidence that the resident could and did reposition herself in bed from her side to her back. The charge in the Administrative Complaint was that Brynwood failed to provide care to prevent a pressure ulcer, not that Brynwood failed to provide care to treat a pressure ulcer. Therefore, the testimony of the investigator regarding instances on which the resident was observed to be on her back, suggesting a failure to turn and position the resident, is irrelevant. Even if the charge had been failure to treat, the evidence presented did not support such charge given the fact that the resident could and did often reposition herself. Given these facts, the evidence did not demonstrate that Tag 314 had been violated by Respondent.
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 revising the April 25, 2002, survey report by deleting the deficiencies described under Tag F-309 and Tag F-314 and issuing a Standard rating to Brynwood to replace the previously issued Conditional rating; correcting all other records to reflect the absence of any proven deficiencies at Brynwood during either survey; and dismissing the Administrative Complaint. DONE AND ENTERED this 21st day of February, 2003, in Tallahassee, Leon County, Florida. DIANE CLEAVINGER 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 21st day of February, 2003. COPIES FURNISHED: Joanna Daniels, Esquire Agency for Health Care Administration 2727 Mahan Drive Building 3, Suite 3408D Tallahassee, Florida 32308 Donna H. Stinson, Esquire Broad & Cassel 215 South Monroe Street, Suite 400 Post Office Drawer 11300 Tallahassee, Florida 32302 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 3 Tallahassee, Florida 32308 Valda Clark Christian, General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building 3, Suite 3431 Tallahassee, Florida 32308
