Findings Of Fact The Respondent, Colonial Palms, Inc., is licensed to operate Colonial Palms Nursing Home in Pompano Beach, Florida, as a nursing home facility, pursuant to Chapter 400, Part I, Florida Statutes, and Chapter 10D-29, Florida Administrative Code. On December 15, 1981, two representatives from the Petitioner visited the Respondent's facility in connection with its annual license survey. On this occasion the following conditions were found which were in violation of the applicable provisions of the Florida Administrative Code. Supervision of all details of nursing care to patients was not being fulfilled by the Nursing Supervisor in that: The charge nurses were not monitoring the functions of the clean and soiled utility rooms, as evidenced by mixed clean and soiled functions in the rooms. Personal luggage of patients was stored in a soiled utility room, clean foam padding was stored on a shelf in a soiled utility room. Three weeks staffing was reviewed. There was no RN on duty during the AM shift on 4 out of 21 days, 11/22, 11/28, 11/29, 12/12/81, when the average census was 74 patients. Patients' rights were violated in 4 charts reviewed in that the patients were not advised of their full rights as promulgated by the 1980 Legislature. Written consultation reports from a consulting dietitian to the Administrator were not available for review for the months of April, May, June, July, 1981. The dietary department lacked the required test kit that measures the parts per million concentration of the sanitizing solution used to sanitize the patient trays, as well as the multi use pots and pans. The hood above the cook's range, the sprinkler system, and the electric lights were soiled with a grease encrustation. Medications being administered by the nursing staff consisted of controlled and prescription drugs which were not stored in locked cabinets, but were stored on side carts exposed and accessible to all patients. The soiled utility room in the south wing was not equipped with a flushing rim clinical service sink having a wide area service trap with bedpan flushing equipment. The Respondent nursing home was given until January 15, 1982, to correct all of the conditions described above. On February 8, 1982, a follow-up visit was made to the Respondent nursing home. On this occasion the conditions described above at subparagraphs (a), (c), (d) and (f) had been corrected. The conditions described at subparagraphs (b), (e), (g) and (h) above had not been corrected. The flushing sink mentioned in subparagraph (h) above had been ordered from the nursing home's supplier on December 20, 1981. However, due to a delay in shipment, it was not received until July or August, 1982. It is now in place, as required. The remainder of the conditions which existed on February 8, 1982, are now corrected.
Recommendation From the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Colonial Palms, Inc., d/b/a Colonial Palms Nursing Home, be found guilty of four separate violations on one occasion after the specified date for correction, and that Colonial Palms, Inc., be assessed an administrative fine in the amount of $400.00. THIS RECOMMENDED ORDER entered on this 30 day of November, 1982, in Tallahassee, Florida. WILLIAM B. THOMAS 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 30th day of November, 1982. COPIES FURNISHED: Harold Braynon, Esquire 201 West Broward Boulevard Fort Lauderdale, Florida 33301 William L. Pace Administrator of Colonial Palms Nursing Home 51 West Sample Road Pompano Beach, Florida 33064
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 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
