The Issue The issues to be resolved in this proceeding concern whether the Respondent is guilty of a violation known as a "Class II violation" or "deficiency" and, if so, whether a $2,500.00 fine and conditional licensure status should be imposed upon the Respondent facility.
Findings Of Fact The Agency for Health Care Administration (AHCA or Agency) is the regulatory agency charged with licensure and enforcement of all applicable statutes and rules governing skilled nursing facilities and the appropriate provision of nursing and other elements of care in such facilities in Florida. The Respondent Haven of Our Lady of Peace, Inc., (Haven) owns and operates a skilled nursing facility, which is a 120 bed facility located in Pensacola, Florida. On July 20, 2004, a survey was conducted by AHCA of the Haven facility. One Agency representative was on the premises on July 20, 2004, to investigate a complaint received by the Agency. When the survey was made the facility was operating under a standard license (Number SNF11970951) issued by the Agency, with an effective date of July 1, 2004 through June 30, 2005. Haven was cited for a Class II deficiency and issued Notice of a Conditional License and a $2,500.00 fine as a result of the survey. It chose to contest this initial Agency action by availing itself of the right to a formal proceeding pursuant to Section 120.57(1), Florida Statutes. The basis of the charged Class II deficiency was an incident involving Resident 3, in which she fell from a seated position in a wheelchair, injuring her head. At the time of the incident an order had been written by the treating physician assigned to Resident 3, which read as follows: D/C lap buddy. D/C lateral supports. Velcro torso support while in w/c [wheelchair]. Release Q2 for toileting, exercise, repositioning. As a result of the survey, the Agency provided Haven with a "Statement of Deficiencies" stating upon what basis the purported Class II deficiency was believed to exist. Resident 3 experienced a fall when she turned over her wheelchair in July 2003 by leaning to far to the right. Haven, in response to this experience, tried several approaches to help Resident 3 when she was in the wheelchair. Lateral supports and "lap buddy" were the first two interventions. The lap buddy caused the resident aggravation and therefore was discontinued and the torso support device was implemented. The torso support was not a restraint, but rather was applied to assist Resident 3 in maintaining good position while in her wheelchair. While Resident 3 had fallen on several occasions, she had never fallen or leaned forward prior to the subject falling incident. If Resident 3 had previously leaned forward, then other devices, such as wedge cushions, would have been used rather than the torso support. The torso support is not a good device to use if a resident falls forward. The torso support was not intended to directly prevent falls. On July 17, 2004, Kathy Anderson, a Certified Nursing Assistant (CNA), was preparing Resident 3 for bed. Ms. Anderson took Resident 3 from the living room, at which Resident 3 had a torso support on, in her wheelchair to the bathroom in Resident 3's room. The torso support was taken off so that the resident could use the bathroom. Ms. Anderson, as she had done on many occasions while caring for Resident 3, then placed her in a good position in the wheelchair, without applying the torso support and pushed her several feet into the bedroom and placed the wheelchair perpendicular to her bed, with the wall at the right side of the wheelchair (to prevent the feared fall to the right based upon a past tendency of the resident to lean to the right). Ms. Anderson had leaned Resident 3 back in the wheelchair prior to moving her from the bathroom. During the many times Ms. Anderson had cared for Resident 3 she had never leaned forward in her wheelchair. Ms. Anderson determined, while in the bathroom, that the resident's diaper was wet and a dry diaper was needed. The diapers were located in a closet just outside the bathroom. Ms. Anderson, standing at the back of the wheelchair, when it was positioned as described above in the resident's room, was able to reach into the closet and obtain a diaper without losing sight of the resident. It was not necessary for Ms. Anderson to walk to the closet, as the distance was close enough for her to reach the diaper without other movement. As she had done in the past, Ms. Anderson had instructed the resident that she was getting a diaper. The resident was still sitting in the wheelchair when Ms. Anderson had the diaper in hand. The resident then suddenly leaned forward and fell from the wheelchair and struck her head on the bottom of the bed. Ms. Anderson tried to catch the resident when she saw her falling, but was unsuccessful. Ms. Anderson then called a nurse, Joyce Parks, and Resident 3 was placed in her bed. Dr. Holmes' order (and his testimony) provided that the supports should be released at least every two hours. The torso support is not worn when the resident is in bed. The torso support must be removed to change the resident's clothes. There was no reason for the torso support to be re- applied after the resident used the bathroom. Ms. Anderson provided appropriate supervision of Resident 3 and her actions did not violate Dr. Holmes's order. The fall that occurred on July 17, 2004, was unforeseeable as the resident had never leaned forward before, but had always leaned to the right after she had been sitting for a long time and grew tired. Further, the resident had been placed in the bed after using the bathroom by Ms. Anderson using the same procedure during the two months that Ms. Anderson had cared for the resident. Resident 3 was in the nursing home for about two years. Dr. Holmes advocated that the residents be restrained as little as possible. According to Dr. Holmes, Resident 3 was a "delightful lady" and the applying of a restraint would have negatively impacted her quality of life. The relevant regulation applicable to nursing facilities requires that anything that restricts a resident be classified as a restraint; therefore, Haven was required to list the torso support as a restraint. In actuality, the torso support was not and did not function as a restraint. A torso support is applied to position the resident more straight and in a better position in a wheelchair. A torso support allows a resident to sit more straight for a longer period of time, to be more comfortable and thereby enjoy a better quality of life. It was reasonable for Ms. Anderson to be standing behind the wheelchair when she wheeled Resident 3 out of the bathroom and into the bedroom. The resident's ability to reach her highest practicable mental, physical and psycho-social well- being was not compromised by the Haven staff in this instance. Resident 3 received adequate supervision and assistance devices on July 17, 2004, when this incident occurred.
Recommendation Based on the foregoing Findings of Fact, Conclusions of Law, the evidence of record, the candor and demeanor of the witnesses, and the pleadings and arguments of the parties, it is, therefore, RECOMMENDED that a final order be entered by the Agency for Health Care Administration, dismissing the Amended Administrative Complaint in its entirety; that no fine be assessed, and that the Respondent be granted a standard license for the period of time in question. DONE AND ENTERED this 24th day of June, 2005, in Tallahassee, Leon County, Florida. S P. MICHAEL RUFF 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 24th day of June, 2005. COPIES FURNISHED: Janis L. Rosenthal, Esquire Agency for Health Care Administration Fort Knox Building III, Mail Station No. 3 2727 Mahan Drive, Building 3 Tallahassee, Florida 32308 Karen Goldsmith, Esquire Jonathon Grout, Esquire Goldsmith, Grout & Lewis, P.A. 2180 Park Avenue North, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 William Roberts, Acting General Counsel Agency for Health Care Administration Fort Knox Building, Suite 3431 2727 Mahan Drive Tallahassee, Florida 32308
The Issue Should Petitioner's license rating have been changed from "Standard" to "Conditional" based on the allegation that Petitioner failed to properly monitor a resident with bilateral edema of the lower and upper extremities?
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: The Agency is vested with the statutory authority under Subsection 400.021(2), Florida Statutes (2001), to license nursing homes, including the assigning of a licensure status pursuant to Section 400.102, Florida Statutes (2001). Petitioner is a licensed nursing home facility (Facility) located in Clewiston, Florida. On January 14-17, 2002, the Agency conducted an Annual Re-Certification Survey (Survey) of the Facility and determined that the Facility failed to monitor Resident 15 (the Resident), who was suffering from bilateral edema of the lower extremities. The Agency cited the Facility for one Class II deficiency described by Tag Number F224. By letter dated January 31, 2002, the Agency advised the Facility that its license rating was changed to "Conditional" effective January 17, 2002. During a follow-up survey the Agency was convinced that the deficiencies that resulted in the conditional license status had been corrected and reissued a standard license to the Facility on January 31, 2002. At the time of admission, on October 17, 2001, the Resident was 66 years old and had been diagnosed with Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, with previous renal failure and electrolyte imbalance. The Resident was also receiving Pain Management for Degenerative Joint Disease. The Resident was not suffering from edema at the time of admission. The staff of the Facility and the Resident's physician, Dr. Daniel McIntire, described the Resident as being very active, a social person who was ambulatory and communicative. The Resident was constantly on the move throughout the Facility's hallways and was constantly in the Patio area to indulge in smoking. On November 1, 2001, the nurses notes indicate that the Resident had 2-3+ edema to both feet and that Dr. McIntire was notified. On November 1, 2001, Dr. McIntire examined the Resident and determined that he was suffering from lower leg edema. Dr. McIntire treated the Resident's edema with a short course (40 mg once a day x 4 days) of Lasix. On November 4, 2001, the nurses notes reveal that the Resident had responded to the Lasix treatment and the Resident's edema was resolved. There is no documentation in the nurse's notes that the Resident was being monitored for edema during the period between November 4, 2001, and January 1, 2002. However, the testimony of the Director of Nursing, which I find to be credible, was that the absence of documentation did not mean that the Resident was not being monitored since only exceptions were documented. The documentation in the nurses notes reveal that on January 1, 2002, the Resident was suffering from a 2+ pitting edema in both lower extremities and both arms. Dr. McIntire was notified of the Resident's condition. Dr. McIntire placed the Resident on Lasix (40 mg once a day x 5 days). Between January 1, 2002, and January 8, 2002, there was no documentation in the clinical record of monitoring for the edema or for the effectiveness of the diuretic, Lasix. On January 9, 2002, the documentation in the clinical record reveals that the Resident had generalized edema in the lower extremities and arms. Dr. McIntire was informed of the Resident's condition. Dr. McIntire ordered Keflex (an antibiotic) for the Resident and referred him to the Pain Clinic. There is no evidence that the pain suffered by the Resident was caused by the edema. On January 14, 2002, during a group meeting, the Resident advised one of the Agency's surveyors that his feet were swollen and that he was having trouble putting on his shoes. The Resident stated that he had no pain in his feet when he walked with his walker but that his shoes did not fit. There is no documentation in nurses notes indicating that the Resident's edema was being monitored from January 9, 2002, until January 16, 2002, when Agency's surveyor advised the Facility's nurse that the Resident's feet were swollen. Upon examining the Resident, the nurse determined that the Resident had bilateral edema of his lower legs and feet and right lower arm. On January 16, 2002, the nurse notified Dr. McIntire that the Resident was suffering from edema. Dr. McIntire placed the Resident on Lasix (20 mg once a day x 5). The Nurses notes of January 17, 2002, revealed that Dr. McIntire increased the dosage of Lasix for the Resident to 40 mg once a day x 3 days. Dr. McIntire visited the Facility regularly, between November 4, 2001, and January 1, 2002, and encountered the Resident on a regular basis during those visits. Dr. McIntire did not observe the Resident suffering from any further edema between November 4, 2001, and January 1, 2002. Although the Resident gained considerable weight during his period of stay at the Facility, there is no evidence that his weight gain was the result of the edema. In fact, the Resident's weight gain was most likely the result of his poor eating habits. The Resident was constantly eating snacks in addition to his regular meals. Although there is a lack documentation that the nurses or Dr. McIntire was monitoring the Resident's edema during his stay at the Facility, there is sufficient evidence to establish facts to show that the Facility was monitoring the Resident's edema throughout his stay in the Facility. Other than his comment to the survey member on January 14, 2002, concerning his swollen feet, the Resident made no complaint concerning his feet being swollen to the point that he could not put on his shoes or that the edema was causing him any pain.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Agency enter a final order rescinding the conditional licensure status issued to the Facility on January 17, 2002, and reinstate the standard licensure status for the period in question. DONE AND ENTERED this 9th day of September, 2002, 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 (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 9th day of September, 2002. COPIES FURNISHED: R. Bruce McKibben, Jr., Esquire R. Bruce McKibben, P.A. 1435 East Piedmont Drive Suite 214 Tallahassee, Florida 32308 Gerald L. Pickett, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Sebring Building Suite 310H St. Petersburg, Florida 33701 Lealand McCharen, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308 William Roberts, Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
The Issue Whether Respondent should be issued a Conditional rating from March 15, 2001, to June 11, 2001, based on surveys completed on March 15, 2001, and April 19, 2001.
Findings Of Fact Plantation Bay is a nursing home located in St. Cloud, Florida. Every fifteen months AHCA conducts a survey to determine if the facility is in compliance with applicable regulatory standards. During a survey, surveyors will observe and interview residents, observe care that is administered to residents, review medical records, and interview staff and family members. Based on the results of the surveys AHCA conducts, it determines whether the facility should receive a Standard or Conditional licensure rating. After AHCA completes the survey of a nursing home, it issues a report of its findings, commonly called a "2567," which describes any deficiencies found by the surveyors. The deficiencies are organized by "Tags." A Tag identifies the applicable regulatory standard that the surveyors believe has been violated and provides a summary of the violation, specific factual allegations that the surveyors believe support the violation, and two ratings which indicate the severity of the deficiency. One of the ratings identified in a Tag is a "scope and severity" rating, which is a letter rating from A to L with A representing the least severe deficiency and L representing most severe. The second rating is a "class" rating, which is a numerical rating of I, II, or III, with I representing the most severe deficiency and III representing the least severe deficiency. AHCA conducted a survey of Plantation Bay, on March 15, 2001, and alleged that there were three deficiencies, which it described under Tags F224, F309, and F332 of a survey report. AHCA assigned a state class rating of II and a federal scope and severity rating of G to both the F224 and F309 deficiencies. A scope and severity rating of "G" is one which AHCA determines is an isolated deficiency that caused actual harm (that is not immediate jeopardy) to a resident. AHCA assigned a state class rating of III and a federal scope and severity rating of E to the F332 deficiency. Based on its determination that there were two Class II deficiencies at Plantation Bay, AHCA changed Plantation Bay's licensing rating from Standard to Conditional, effective March 15, 2001. AHCA conducted a follow-up survey of Plantation Bay on April 19, 2001, to determine if the deficiencies cited on March 15, 2001, had been corrected. AHCA determined that the facility had corrected the F224 and F309 deficiencies but, based on new factual allegations, re-cited Plantation Bay for a deficiency under Tag F332. The F332 deficiency was assigned a Class III rating and a scope and severity rating of E. Because AHCA believed this deficiency had not been corrected, AHCA continued the Conditional rating at Plantation Bay. AHCA changed Plantation Bay's Conditional licensure rating to Standard, effective June 11, 2001. In the March 15, 2001, survey AHCA alleged under Tag F224 that Plantation Bay violated the standard contained in 42 CFR Section 483.13(c) and under Tag F309 that Plantation Bay violated the standard contained in 42 CFR Section 483.25. AHCA contends that Plantation Bay failed to provide appropriate monitoring and care to Resident 10 in relation to Tag F224 and failed to reduce the risk of potential decline and to maintain the highest practicable physical well being for Resident 10 in relation to Tag F309. Plantation Bay has procedures which the nursing staff are to follow when a resident has an elevated blood pressure level. The nurse is to continue to monitor the resident's blood pressure, notify the next shift of the resident's blood pressure, and contact the resident's physician if the resident's blood pressure continues to be elevated. Resident 10 was diagnosed with cardiovascular disease, cerebral vascular accident, hypertension, and cardiac dysrhythmia. She was prescribed 20 milligrams of Monopril every 12 hours. On March 2, 2001, a nurse measured Resident 10's blood pressure level at 210/90, which was a high reading for Resident 10. Standard nursing procedure called for the attending nurse to continue monitoring Resident 10's blood pressure and to notify the oncoming nursing staff and Resident 10's physician. The nurse failed to do any of these things. On March 4, 2001, Resident 10's family complained to Plantation Bay about Resident 10's cough and congestion. A nurse took Resident 10's temperature, but did not take Resident 10's blood pressure level. On March 12, AHCA's surveyor, in reviewing Resident 10's Vital Sign Flow Record, noted that from May 20, 2000, to March 2, 2001, the highest blood pressure recorded in Resident 10's Vital Sign Flow Record had been 184/72. The surveyor further noted that no further monitoring had been done since March 2, 200l. When the AHCA surveyor interviewed the nurse who had taken Resident 10's blood pressure level on March 2, 2001, and asked why no further monitoring had been done, the nurse replied that another emergency had occurred during her shift on March 2, 200l, and she had done nothing about the high blood pressure reading because it had "slipped her mind." On March 13, 2001, when the AHCA surveyor noted the lack of monitoring Resident 10's blood pressure level since March 2, 2001, she asked the nurse on duty whether she was aware that Resident 10 had an elevated blood pressure on March 2, 2001. The nurse replied that she was not aware of the elevated blood pressure. The nurse checked Resident 10's blood pressure, which was 202/82. The nurse indicated that she was going to contact Resident 10's physician. The surveyor asked what Resident 10's temperature was, and the nurse replied that she had not checked the temperature. Thirty minutes later, the nurse checked Resident 10's temperature and blood pressure. The temperature was 99.6 degrees Fahrenheit, and the blood pressure was 210/100. This information was sent to Resident 10's doctor. An hour and a half later, Resident 10's blood pressure was 210/90. Ninety minutes later, the blood pressure was 210/100. The information had been sent to Resident 10's doctor, but the doctor had not responded. Two and a half hours later, Resident 10 was sent to the emergency room by order of her physician. Resident 10's medication was changed to 40 milligrams of Monopril every 12 hours. An elevated blood pressure could worsen cardiovascular disease, cerebral vascular accident, hypertension, and cardiac dysrhythmia, conditions with which Resident 10 had been diagnosed. Thus, the failure of Plantation Bay on March 2, 2001, to monitor the blood pressure, to report the elevated blood pressure level to the oncoming shift, and to notify Resident 10's physician had a direct relationship to the health of Resident 10 and imposed an immediate threat to the health of Resident 10. AHCA also alleged under Tag 309 from the March 15, 2001, survey that Plantation Bay violated the standard of care set forth in 42 CFR Section 483.25. Plantation Bay failed to provide the necessary care for Resident 16 by not reducing the risk of potential decline and not maintaining the highest practicable physical well-being of each resident when it failed to monitor Resident 10's blood pressure on March 2, 2001, failed to notify the oncoming shift of the elevated blood pressure level, and failed to contact Resident 10's doctor. Resident 16 was admitted to Plantation Bay on February 10, 2001, following hospitalization for hepatic encephalopathy, secondary to cirrhosis of the liver, seizures, and falls. As a result of hepatic encephalopathy, the liver is unable to remove all the ammonia that it produces, and there is a risk that some ammonia will be introduced into the heart and brain. Prior to his admission to the hospital, Resident 16's ammonia level was 96. When Resident 16 was admitted to Plantation Bay, the ammonia level was 33, which is within normal range. Production of stool is important to reduce the absorption of nitrogen into the intestinal tract. On February 11, 2001, Resident 16's physician ordered 30 milligrams of Lactulose to be administered three times daily to produce at least three stools daily and to prevent hepatic encephalopathy. Plantation Bay administered the Lactulose to Resident 16 as ordered by the resident's doctor. According to Resident 16's Documentation Charting Record, the order text on February 10, 2001, was to "Monitor BMs & chart daily with O-S-M-L." Plantation Bay did monitor Resident 16's bowel movements and prepared a daily chart on the number and size of the bowel movements. Plantation Bay was not required to call the doctor if Resident 16 did not have three bowel movements a day. On February 11, 2001, Resident 16 had two bowel movements and one bowel movement on February 12, 2001. Blood tests on February 12, 2001, revealed that Resident 16 had an elevated ammonia level of 77, which is 17 points higher than normal. Plantation sent the test results to Resident 16's physician. The policy of Plantation Bay was to also place a copy of a laboratory report in the resident's chart. Resident 16's doctor went to the facility to see Resident 16 on February 13, 2001. The doctor did not change Resident 16's dosage of Lactulose nor did he make any notation about the number of Resident 16's bowel movements in the physician's notes. The charting records for Resident 16 show that from February 13 through March 15, there were 13 days when Resident 16 had no bowel movements, ten days in which Resident 16 had one bowel movement, five days in which Resident had two bowel movements, and one day in which there were three bowel movements. On April 5, 2001, Resident 16's physician stated in the Physician's Progress Notes for Resident 16 that Resident 16's ammonia levels had been fluctuating for four years, this was a chronic condition, and the fluctuation had nothing to do with the nursing care provided by Plantation Bay. He indicated that the ammonia levels were only a marker of the resident's condition. The nursing care provided by Plantation Bay did not cause the fluctuation in Resident 16's ammonia level and that the nursing staff followed the orders of the doctor in administering the Lactulose, monitoring the bowel movements, and charting the bowel movements daily. AHCA alleged under Tag F332 that Plantation Bay violated 42 CFR Section 483.25(m)(1), which requires that the facility is to be free of medication error rates of five percent or greater. AHCA contends that during the March 15, 2001, survey Plantation Bay had a medication error rate of 10.8 percent during observations of med passes on March 13, 2001. AHCA contends that during the April 19, 2001, survey that Plantation Bay had a medication error rate of 11.6 percent. In determining if a medication error has occurred, the surveyors observe a nurse as medications are administered to a resident, and then will look at the physician's orders to see if the medications are administered in accordance with the physician's orders. If a medication is administered but not ordered, it is counted as a medication error. If a medication is ordered but not administered, it is counted as a medication error. If a medication is not administered in accordance with the physician's order, it is also counted as a medication error. The errors are counted regardless of how significant they might be. The two AHCA surveyors who did the med pass observations for Tag F332 had extensive training in surveying and followed the procedures for surveying violations of Tag F332 as set forth by the Health Care Financing Administration (HCFA) in the Guide to Surveyors and Task E of the survey protocols, which provides: Initially observe a minimum of 20-25 opportunities for errors (opportunities are both the drugs been administered and the doses ordered but not administered). Strive to observe as many individuals administering medications as possible. This provides a better overall picture of the accuracy of the facility's entire drug distribution system. Ideally, the medication observation could include residents representative of the care needs in the sample, or the actual sampled residents. This would provide additional information on these residents, and provide a more complete picture of the care they actually receive. For example, if blood sugars are a problem, insulin administration may be observed. If eye infections are a problem, antibiotic eye drops may be observed, if residents are in pain, as needed pain medications may be observed, etc. Observe different routes of administration (i.e., eye drops, injections, NG administration, inhalation). If you found no errors after reconciliation of the pass with the medical records, this task is complete. If you found 1 or more errors, observe another 20 to 25, opportunities. The error rate is calculated by taking the number of errors observed and dividing it by the opportunities for errors and multiplying by 100. During the March 15, 2001, survey, an AHCA surveyor observed two medication errors during medication pass out of 24 opportunities for administration of medicine. These errors were the administration of 220 milligrams of iron when 325 milligrams were ordered and the administration of 25 milligrams of Colace when 100 milligrams were ordered. Colace is a stool softener. During the March 15, 2001, survey, another AHCA surveyor observed three errors out of 22 opportunities for administration of medicine. These errors were the omission of 20 milligrams of Pepcid to be administered once daily, the administration of 500 milligrams of Vitamin C when there was no physician's order, and the administration of two drops of Tobra Dex Opthalmic eye drops when one drop was ordered by the physician. During the April 19, 2001, survey an AHCA surveyor observed five errors out of 43 opportunities. These errors were failure to give Maalox with ibuprofen as ordered, administration of one drop of Gentamycin sulphate when two drops were ordered, administration of a multivitamin without iron when one with iron was ordered, administration of 1.20 milligrams of Prozac when 1.25 milligrams were ordered, and giving Lactolose after breakfast at 9:20 a.m. when it was ordered to be given before breakfast at 7:00 a.m. Plantation Bay challenges the methodology used by AHCA to determine the medication error rate. Plantation Bay's expert witness opined that a larger sampling would have to be used in order to get a more statistically valid error rate. According to their expert, a sampling of over 3,000 opportunities would be necessary in order to reach an error rate which was 80 percent correct. No evidence was presented to show the number of opportunities for administration of medications that the facility had in a day. Thus, it is not known if the facility even had 3,000 opportunities a day. The evidence failed to support Plantation Bay's expert's opinion that over 3,000 opportunities would have to be observed in order to accurately determine the medication error rate for Plantation Bay is credible. Contrary to the assertion of AHCA that the purpose of the med pass observations is to get a snap shot of one moment in time for the opportunities actually observed and not to make a projection as to what the error rate is for all the medication administrations in the building, Task E of the survey protocols makes it clear that the purpose of the med pass observations is to get a better "overall picture of the accuracy of the facility's entire drug distribution system." However, that error rate is obviously limited to the time of the survey. Given the short time period in which a survey is conducted, the methodology that is used to determine the medication error rate of the facility at the time of the survey is not fatally flawed. If the surveyor finds that an error occurs in observing the first 20 to 25 opportunities, the surveyor is to observe further opportunities to ascertain if there are errors in that group of observations. For the March 15, 2001, survey, Plantation Bay had a medication error rate of 10.8 percent. For the April 19, 2001, survey, Plantation Bay had a medication error rate of 11.6 percent. The Conditional Rating was effective from March 15, 2001, to June 11, 2001. No evidence was presented to establish when Plantation Bay was re-evaluated and a determination made that medication error was less than five percent.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that a final order be entered finding that Plantation Bay receive a Conditional license from March 15, 2001, through June 11, 2001. DONE AND ENTERED this 2nd day of November, 2001, in Tallahassee, Leon County, Florida. ___________________________________ Susan B. Kirkland Administrative Law Judge Division of Administrative Hearings 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 this 2nd day of November, 2001. COPIES FURNISHED: Patricia J. Hakes, Esquire Agency for Health Care Administration 525 Mirror Lake Drive, North Room 310J St. Petersburg, Florida 33701 R. Davis Thomas, Jr. Qualified Representative Broad and Cassel 215 South Monroe Street, Suite 400 Post Office Box 11300 Tallahassee, Florida 32302-1300 Diane Grubbs, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308 William Roberts, Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive Fort Knox Building, Suite 3431 Tallahassee, Florida 32308
The Issue The primary issue for determination is whether Windsor Manor (Respondent) committed the deficiencies as alleged in the Amended Administrative Complaint dated September 29, 2004. Secondary issues include whether Petitioner should have changed the status of Respondent's license from Standard to Conditional for the time period of April 30, 2004 until June 7, 2004; and whether Petitioner should impose administrative fines for alleged deficiencies that are proven to be supported by the evidence.
Findings Of Fact Petitioner is the state agency responsible for licensing and regulating nursing homes in Florida pursuant to Section 400.23(7), Florida Statutes (2004). Respondent is licensed to operate a nursing home located at 602 East Laura Street, Starke, Florida 32091 (the facility). Petitioner's personnel conducted a complaint survey of Respondent's facility on April 29 and 30, 2004. Upon completion of that survey, Petitioner survey personnel prepared a report that charged Respondent with a violation of one nursing home regulation. This report identifies the deficiency as a violation of 42 C.F.R. Section 483.25 as made applicable to licensed nursing homes in Florida pursuant to Florida Administrative Code Rule 59A-4.1288. Petitioner rated this alleged deficiency as having a scope and severity of "Class II." The alleged deficiency involves one resident, identified as Resident 4, at the facility and relates only to the incidents that occurred between midnight and 3:30 a.m. on the morning of April 20, 2004. Resident 4, an 85-year-old woman, was admitted to Respondent’s facility on December 17, 2003, with diagnoses of deep vein thrombosis, congestive heart failure, cerebral vascular disease, hip pain, degenerative joint disease, and dementia. Upon her admission, she was evaluated by Respondent and a care plan was prepared that identified 15 areas of concern for her. The relevant portion of Resident 4’s care plan was finding number 2, that the resident is at "risk for injury/falls." Among the steps listed to deal with this problem were to make sure that her call bell was within reach when Resident 4 was in bed; keeping the bedrails up and the bed in its lowest position when she was in bed; reminding her to request assistance when getting out of bed or out of her wheelchair; and the use of technological devices (personal alarms) to enhance safety “as needed.” In the early morning hours of April 20, 2004, Resident 4 was sitting in her wheelchair at the nurses’ station. This was not unusual for this resident, although she had been given Ambien, a sleeping pill, earlier in the evening in accord with her physician’s orders. At about 12:30 a.m., Resident 4 complained that she was unable to sleep due to pain in her left hip. This was evaluated as a fairly serious complaint as the pain rated an “8” on a scale of 1 to 10. She was given Lortab, a pain reliever, to deal with her pain, a medication also authorized by her physician’s orders. At about 1:00 a.m., she said she was sleepy and started to wheel herself toward her room. Shortly thereafter, Resident 4 was located lying on the floor between the nurses’ station and her room. She stated that she had slid out of her wheelchair. Respondent’s staff evaluated her range of motion and did a neurological check and found everything to be normal. There was no apparent sign of injury to Resident 4. In response to questioning, Resident 4 stated that she had not hit her head during her slip and did not complain of any pain. During this evaluation, she was alert and talkative, although she did say that she was sleepy. Staff assisted Resident 4 to a standing position, placed her back in her wheelchair, and took her to her room to put her to bed. When Resident 4 was put into her bed, staff made sure that her bed rails were both fully upright. Her bed was put in its lowest position. Resident 4 was reminded to call for assistance if she wanted to get out of bed. Her call bell was within easy reach. Each of these actions was listed in Resident 4’s Care Plan to minimize her risk of falling. The standard for monitoring residents in nursing homes is once every two hours. Respondent’s staff, however, began to monitor Resident 4 every half hour following her slide out of her wheelchair at 1:00 a.m. At 1:30 a.m., Resident 4 was noted in bed with the side rails up and call light within reach. She was drifting in and out of sleep at this time. At 2:00 a.m., she was observed in bed with her bed rails up and the call light in reach. One-on-one monitoring was not be required as a standard of care for her at this time. During the next monitoring visit at 2:30 a.m., Resident 4 was observed lying on the floor; her bed rails were still in the upright position. She had never previously attempted to get out of her bed when the side rails were in the up position. At that time she was evaluated and found to have a hematoma (a large knot or pooling of blood under the skin) on her upper left forehead. Staff evaluated her range of motion and found it to be normal, a neurological check also found her mental performance to be normal. She did not complain of pain at that time and, but for the hematoma, appeared normal in every respect. An ice pack was applied to the hematoma. Respondent’s staff called Resident 4's physician, and Resident 4's daughter to inform them of this incident. Staff determined that they would take Resident 4 back to the nurses’ station for continuous direct monitoring and assessment. She was placed in her wheelchair and taken out of her room. While being wheeled to the nurses’ station, she suddenly jammed both of her feet into the floor, pitching herself out of her wheelchair before the nurse could catch her. The nurse was immediately behind Resident 4 wheeling her in her wheelchair at the time of this fall. During this fall she again hit the upper left area of her forehead. Respondent initiated neurological checks on Resident 4 every 15 minutes. The neurological checks done at 2:30 a.m., 2:45 a.m., 3:00 a.m. and 3:15 a.m. all show normal vital signs and responses. The 3:30 a.m. neurological check, however, revealed that her pupils had dilated, she had become restless and disoriented, and her reaction time had visibly slowed. Respondent immediately called Resident 4’s doctor to inform him of this change in condition. An order was given to transport her to the hospital. The ambulance arrived at Respondent’s facility almost immediately to transport Resident 4 to the hospital, and her daughter was also immediately informed of these events. Nursing homes are required to fully assess every resident and to develop a care plan to address each of the specific problem areas identified for each individual resident. The care plan is prepared by an interdisciplinary team consisting of every discipline within the nursing home, and guides the nursing staff in caring for the residents. Resident 4’s care plan contained 15 identified problem areas and was approximately 75 pages in length. During the survey, Petitioner asked the nurse who cared for Resident 4 on the night of April 20, 2004, if she was aware of the care plans for this resident. That nurse stated that she did not recall ever reading Resident 4’s individual care plan. The nursing staff was not, however, totally unaware of the requirements of the care plan since a great deal of information and action steps used in the care of residents like Resident 4 are contained in alternative documentation maintained by Respondent. Respondent has distilled the action steps of the care plan down to a list of approaches for its nursing staff. This document contains all of the nursing approaches to resident care and is kept at the nursing station for ready reference. Petitioner was able to locate the “Approaches” document for Resident 4 during the survey. Among the items listed in Resident 4’s Care Plan and also listed in the “Approaches” document were to put her bed rails in the up position; to put her bed in the lowest position; to remind her to call for assistance when she wanted to get out of bed; and to make sure that her call button was within easy reach. The staff at Respondent’s facility carried all of these steps out, demonstrating an awareness of the required actions necessary for the care of Resident 4, and effectively complying with the care plan. One of Petitioner's concerns was the lack of use technological devices by Respondent personnel to enhance Resident 4's safety; she did not have a personal alarm at any time on April 20, 2004. A personal alarm is a buzzer that is attached to the resident’s bed or wheelchair and is clipped to the resident with an alligator clip. When the resident gets out of the wheelchair, or gets out of the bed, the buzzer goes off alerting staff that the resident is no longer in the wheelchair or bed. A personal alarm is not a restraining device and it will not keep a resident in bed or in a wheelchair. It simply alerts staff when a resident has exited the bed or chair. Under the Resident’s Bill of Rights, a nursing home resident has the right to be free of unnecessary restraint except as ordered by a physician. § 400.022(1)(o), Fla. Stat. There was no physician’s order to restrain Resident 4 and no documentation that restraints would be appropriate. Resident 4 had not slipped from her wheelchair in almost two months before her first fall on the night in question. She had been in physical therapy to improve her strength and there was no indication that she needed an alarm to remain in her wheelchair. She had never fallen from her bed previously. Since she was sleepy and heavily drugged, there was no reason to expect that she would start this behavior at this time. She had never pitched herself out of her wheelchair previously. Respondent's personnel had no reason to believe she would do so on this night. Resident 4 was continuously monitored for falls and approaches to prevent falls; there was no order for a personal monitor at all times, but only on an "as needed" basis. A personal monitor had not been indicated by the patient's previous behavior, and would not have made a difference, on the night of April 20. Petitioner's concern that Respondent should have sent Resident 4 to the hospital earlier in view of the fact that she was taking Coumadin, a blood thinning agent that would have hindered the healing of her hematoma, must be considered in that context that Respondent's right to undertake such action is limited to emergency situations, absent a physician's order. The record reflects that Resident 4 did not display any adverse effects from her second or third fall for a period of one hour. Her physician’s office was notified immediately upon the second fall and no order to transfer was given. When her condition changed, her physician was again notified and this time he directed that she be sent to the hospital. Resident falls are a fact of life at nursing homes. Standard protocol after a fall is to assess the resident and inform the doctor. Respondent's personnel acted appropriately.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Petitioner enter a final order dismissing its Administrative Complaint and restoring Respondent’s license rating of “standard” for the period April 30 through June 7, 2004. DONE AND ENTERED this 24th day of May, 2005, in Tallahassee, Leon County, Florida. S DON W. 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 24th day of May, 2005. COPIES FURNISHED: Jay Adams, Esquire Broad and Cassel Post Office Box 11300 Tallahassee, Florida 32302 Joanna Daniels, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 Richard Shoop, Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308 William Roberts, Acting General Counsel Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308
The Issue In DOAH Case No. 04-0025, the issue is whether the Agency for Health Care Administrative (AHCA) correctly assigned conditional licensure status to Lady Lake NH, L.L.C., d/b/a/ Lady Lake Specialty Care Center (Lady Lake) for the period of August 26, 2003, through October 3, 2003. In DOAH Case No. 04- 1065, the issues are as follows: (a) whether Lady Lake committed a violation of 42 C.F.R. Section 483.25, as it relates to care of patients with or who develop pressure sores; (b) whether Lady Lake committed a violation of 42 C.F.R. Section 483.75, as it relates to clinical records; and (c) if so, what, if any, penalty should be imposed.
Findings Of Fact AHCA is the agency that is responsible for licensing nursing homes and for enforcing Chapter 400, Part II, Florida Statutes, and Florida Administrative Code Chapter 59A-4. This includes enforcement of federal nursing home regulations in the Code of Federal Regulations specifically referenced in this case. Lady Lake owns and operates Lady Lake Specialty Care Center (the facility), a 120-bed skilled nursing facility located in Lady Lake, Florida. The facility operates under license # SNF130470994. At all times material here, the facility was licensed under AHCA's authority. Accordingly, the facility was required to comply with all applicable statutes, rules, and regulations. The facility is a long-term care provider under Medicaid and Medicare. As such, it is subject to federal regulation relating to compliance with 42 CFR Section 483. AHCA has the statutory authority and mandated duty, pursuant to Section 400.23(7), Florida Statutes, to evaluate all nursing homes facilities periodically (at least every 15 months). After each such evaluation, AHCA must assign a licensure status of "standard or conditional" to each licensee. On or about August 26, 2003, AHCA conducted a monitoring survey at the facility. As a result of the survey, AHCA cited the facility for a quality of care deficiency. AHCA based the deficiency upon finding of an alleged lack of proper care of one male resident (hereinafter referred to as "the resident"). More specifically, the citation was for an alleged violation of 42 CFR Section 483.25(c), which pertains to quality of care as it relates to pressure sores. A violation of 42 CFR Section 483.25(c) is commonly referred to as a Tag F-314 deficiency. AHCA determined that the scope of the Tag F-314 deficiency was isolated. AHCA also determined that the nature of the Tag F-314 deficiency was a Class II violation. Pursuant to leave granted, AHCA also charged Lady Lake with violating 42 CFR Section 483.75(l)(1), and/or Section 400.141(21), Florida Statutes, by failing to properly document treatment and care. This violation is commonly referred to as a Tag F-514 deficiency. AHCA determined that the scope of the Tag F-514 deficiency was isolated. AHCA concluded that the Tag F-514 deficiency was a Class II violation. AHCA assigned conditional licensure status to the facility for the period August 26, 2003, to October 3, 2003. AHCA seeks to impose an administrative fine in the amount of $2,500 for the Tag F-314 deficiency and $2,500 for the Tag F-514 deficiency. Lady Lake admitted the 81-year-old resident to the facility on July 31, 2003. At that time, the resident was severely contracted and bedridden. He had much comorbidity, including but not limited to, severe dementia, severe cardiac disease, peripheral vascular disease, end-stage Parkinson's disease, incontinence, cancer, and diabetes mellitus. The resident was non-verbal, non-ambulatory, and emaciated. The resident's records include a Transfer Summary from the Marion County Hospice, dated July 30, 2003. The Transfer Summary indicates that the resident's legs were contracted, that his skin was intact, and that he was using a low-air mattress. When the resident was a patient at the Marion County Hospice, he suffered a number of pressure sores on his feet and legs and at least one Stage III pressure sore on his coccyx. These pressure sores developed at the hospice even though the resident received appropriate care because they were unavoidable given his physical condition. The resident was at "high risk" for pressure sores. He scored a "9" on the Braden Scale for evaluating such risks. A score below "12" is a "high risk" patient. Pressure sores are classified as follows: (a) in Stage I as a persistent area of skin redness (without a break in the skin) that cannot be blanched and which does not disappear within 30 minutes when pressure is relieved; (b) in Stage II as a partial loss in the thickness of skin layers that presents clinically as an abrasion, blister, or shallow crater; (c) in Stage III as a loss of a full thickness of skin layers, exposing the subcutaneous tissues and presenting a deep crater with or without undermining adjacent tissue; and (d) in Stage IV as missing a full thickness of skin and subcutaneous tissues, exposing the muscle and/or bone. Upon admission to the facility, the resident had a red area on the plantar region of the foot below and toward the outer aspect of the great right toe. This red area was a pressure sore in the initial stage with undetermined damaged below. In fact, the resident could have suffered pressure trauma during transit from the hospice to the facility, causing damage to the foot. The facility's Assistant Director of Admissions (ADON) instructed the admission nurse to document the resident's pressure sore so that the facility would not be blamed. However, the admission nurse did not record the red area as a Stage I pressure sore. Instead, she noted that there was no skin impairment with the exception of a reddened area on the outer aspect of the right great toe. She also noted that sheepskin heel protectors were in place. The first charge nurse to attend the resident on the day of his admissions made the same observations. There is no way to determine at the time of a Stage I pressure sore how much underlying tissue has been damaged and how large the wound may become. A wound may look very small, but within a short period of time become huge because there is underlying tissue damage. Additionally, a reddened area on one spot may surface as an open area somewhere else due to underlying tissue damage. The damaged tissue must be removed before new tissue can fill the wound. Tissue damage equates to tissue death. A pressure sore may unavoidably escalate to a Stage III or Stage IV due to tissue damage beneath the skin. This is especially true in cases where the patient, such as the resident here, has severe peripheral vascular disease and lack of adequate blood supply. The healing of the resident's pressure sore was negatively impacted by its location on the foot. The resident's peripheral vascular disease caused a decreased amount of blood circulation to the foot. Further, the resident was not active and therefore was not achieving a good heart rate, which meant that the cardiac output was low. Cardiac output is important in providing blood with oxygen, hemoglobin, and red blood cells to the wound to assist in the healing process. Between the time that the resident was admitted and August 7, 2003, there was no physician order for specific treatment of the reddened area on the resident's foot. There is no persuasive evidence that any such treatment was required. The Weekly Skin Review dated August 7, 2003, identified the damaged tissue on the resident's foot as a pressure sore. The August 7, 2003, Skin Grid indicates that it was a new site of skin impairment that was not present on admission. The pressure sore was documented as a new site of skin impairment because it was no longer just a reddened area typical of Stage I, but had progressed to Stage II, clearly visible as a black/blue area, 3 cm by 3 cm, with no depth or drainage. On August 7, 2003, the resident's doctor ordered a skin preparation to be applied to his right plantar foot region three times daily. At that point in time, the nurses transferred the order to the Treatment Administration Record (TAR), which is just one of the places that the facility uses to document treatment. On the day it was ordered, the treatment was rendered to the resident one time. This is most likely because the facility had to secure the doctor's order and receive the product from the pharmacy before treatment could begin. On August 8, 2003, the nurses on two shifts recorded the skin preparation treatment on the TAR. On August 9 and 10, 2003, all three shifts noted the skin preparation treatment on the TAR. On August 11, 2003, two nurses noted the skin preparation treatment on the TAR. The third nurse presented credible testimony that she provided the treatment even though she did not record it on the TAR. On August 11, 2003, the doctor issued an order for the pressure sore to be cleaned daily, treated with TAO, and covered with non-stick telfa. The TAR reflects that the nurses changed the dressing once on August 12, once on August 14, twice on August 15, once on August 16, twice on August 18, and once on August 20. However, the greater weight of the evidence indicates that the facility's staff complied with the doctor's orders even through they did not always document their treatments. On August 13, 2003, the Weekly Skin Review identified no new areas of skin impairment. The August 14, 2003, Skin Grid notes that the Stage II pressure sore had not changed in size, but was pink in color. On August 20, 2003, the Weekly Skin Review identified no new areas of skin impairment. The August 20, 2003, Skin Grid notes that the Stage III pressure sore had not changed in size or color but had some drainage and minimal odor. On August 21, 2003, the resident's doctor issued an order for the pressure sore to be treated twice a day with Santyl in the middle and TAO on the edges then wrapped with curex until healed. The facility's staff complied with the doctor's orders and recorded the treatments on the TAR twice a day until the doctor discontinued them on August 27, 2003. The resident was placed on the facility's Magnolia Wing. The facility usually places Medicare patients on this wing. The nurses on the Magnolia Wing use Medicare documents such as the forms for Daily Skilled Nursing Notes (DSNN). Because the resident was a private-pay patient, the nurses were not required to document his condition on the Medicare forms on a daily basis. In fact, the nurses were not required to fill out the DSNN at all. They were only required to chart his progress on a weekly basis or when there was a significant change that required charting. The use of the DSNN was at the facility's discretion. Under the facts of this case, the nurses were not expected to check off every box on the DSNN that was relevant or to write a comment on each shift. They were expected to "document by exception," noting anything on their shift that was out of the ordinary for the resident. It is acceptable practice in long-term care nursing to "chart by exception" as it would be insurmountable to chart every thing that a resident does on a daily basis. While the records reflect that some nurses charted routine care of the resident, that charting is indicative of the nurses' training or experience in another setting. The facility's system of documentary communication included, but was not limited to, Nurse's Notes, TAR, and Medication Administration Record (MAR). Other documentary forms were used for skin assessments and wound care treatment. The facility's staff also communicated with each other about the resident's condition by conducting shift-change meetings and nurses' rounds and by checking the dates and nurses' signatures on bandages. These methods of communication met the community standard for good nursing. The nurses and their assistants were not required to document every time they turned and repositioned the resident because it was not an "activity of daily living" for charting purposes. The nurses noted on the TAR that the resident needed to be turned every two hours. They made this notation merely as a reminder to turn the resident. There was no doctor's order to accomplish this task. There was a bear symbol on the resident's door to remind the staff that he needed skin precautions, including turning and repositioning. In any event, turning and repositioning the resident would have had no effect on the foot wound because his foot was not on the bed. Reviewing the MAR, TAR, Nurses' Notes, and DSNN together, there is consistent documentation of treatment being rendered in accordance with the doctor's orders. There is no persuasive evidence that any lack of documentation in the resident's medical records adversely impacted the resident's health and welfare or constituted a deficiency. Lady Lake substantially complied with the requirement to document the care and treatment of the resident. The resident was admitted to the facility on a pressure reduction mattress. The facility provided him with a low-air mattress on August 21, 2003. His mattress was upgraded on two occasions. Providing a long-term care patient like the resident with a pressure-relieving mattress is such a routine intervention that it does not require charting or a doctor's order. Regardless of the type of mattress provided, it did not impact the pressure sore because the resident's foot did not rest on the mattress. On August 26, 2003, AHCA's surveyor asked to observe the resident's wound. A nurse removed the dressing from the resident's foot. AHCA's surveyor had to pry the resident's right foot from where it pressed against his left leg in order to observe the Stage III pressure sore on the ball of the resident's right foot. The wound was crater-like, with irregular edges that were red and meaty looking. The surveyor was unable to determine its depth due to what appeared to be drainage. The bandage could not be reapplied because the nurse assisting the surveyor did not have a key to the medication cart. On August 26, 2003, the wound was covered with a slimy or gelatinous material, which could be attributed at least in part to the Santyl treatment. Santyl is a collagenase debriding agent that dissolves necrotic tissue without causing any harm to the new healing tissue. The use of Santyl can cause a wound to appear gelatinous and green or brown. It would not have been appropriate, at the time of the survey, to remove the gelatinous material from the wound to determine its depth. Because healing starts at the base of the wound, it should not be forcibly cleaned or rubbed. A wound can be left undressed for a period of time if it has not dehydrated. There was no evidence that the resident's wound became dehydrated on August 26, 2003, or at any other point in time. The resident's pressure sore never became infected. An infection would have been likely if he had not received appropriate treatment for the wound. The surveyor did not see any pillows on the bed or in the resident's room. However, the greater weight of the evidence indicates that the resident would have had many more skin problems if the facility staff had not been turning and repositioning him with pillows every two hours. Without pillows, the facility's staff would not have been able to position the resident on his back to feed him. The staff used pillows to separate the resident's legs to relieve the pressure on the foot to the extent possible. Repositioning with pillows is a standard procedure in long-term care facilities. The bandage on the pressure sore acted as padding to eliminate any friction on the pressure sore. The resident's pressure sore never progressed to Stage IV, which requires exposed bone or muscle. The only record of a Stage IV pressure sore is found in the Minimum Data Set (MDS). It is necessary to record a pressure sore as Stage IV on the MDS when it has a blister and the depth cannot be determined. Furthermore, there is no difference in the care rendered to a patient with a Stage III or Stage IV pressure sore. The resident's pressure sore changed to a Stage II before he was transferred out of the facility. The greater weight of the evidence indicates that the resident's ability to reach his highest practicable mental, physical and psychosocial well-being was not compromised by Lady Lake in regard to the quality of care provided or in regard to documenting his condition.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED: That AHCA enter a Final Order dismissing the Administrative Complaints in both cases. DONE AND ENTERED this 15th day of December, 2004, in Tallahassee, Leon County, Florida. S SUZANNE F. HOOD 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 15th day of December, 2004. COPIES FURNISHED: Karen L. Goldsmith, Esquire Goldsmith, Grout & Lewis, P.A. 2180 North Park Avenue, Suite 100 Post Office Box 2011 Winter Park, Florida 32790-2011 Tom R. Moore, Esquire Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308-5403 Charlene Thompson, Acting Agency Clerk Agency for Health Care Administration 2727 Mahan Drive, Mail Station 3 Tallahassee, Florida 32308
