The Issue Whether Respondent committed the Class "II" violation alleged in Counts I and II of the Amended Administrative Complaint and, if so, what sanction(s) should be imposed.
Findings Of Fact Based on the evidence adduced at hearing, and the record as a whole, the following findings of fact are made: The Facility is a 160-bed assisted living facility operated by Respondent and licensed by Petitioner. Resident #1 was admitted to the Facility on or about December 16, 2009, and was a resident of the Facility at all times material to the instant case, including March 21, 2010, May 2, 2010, and May 10, 2010. The "Resident Health Assessment for Assisted Living Facilities" form (Health Form) that was completed in conjunction with Resident #1's admission to the Facility reflected that Resident #1 had a history of alcohol abuse and depression and that, in the opinion of the "examiner" filling out the form, while "[d]aily [o]versight" of Resident #1's "well being and whereabouts" was needed, Resident #1 did not "pose a danger to [him]self or others."5 On March 21, 2010, at around 6:00 p.m., Resident #1 was involved in an incident at the Facility (March 21 Incident). The March 21 Incident was accurately documented (albeit in a manner that was vague and lacking in detail) in the following entry made by Facility staff on the Observation Log maintained at the Facility for Resident #1 (Resident #1's Observation Log):6 Resident [#1] is disoriented at this time and aggressive.[7] He has trouble with other resident [C.].[8] [Resident #1] is very altered and disoriented. I called the doctor for request and sent to the Hospital. I notified to his friend for let to know about the situation.[9] The aftermath of this incident was accurately documented in the following March 21, 2010, 7:00 p.m., entry made by Facility staff on Resident #1's Observation Log: I reported to the police that [Resident #1] is very aggressive and confused. He refused to go to the Hospital. These two entries made by Facility staff on Resident #1's Observation Log constitute the only record evidence concerning the March 21 Incident and its aftermath.10 The record evidence is silent as to the extent to which Resident #1 and the other residents of the Facility, including the one involved in the March 21 Incident, were being supervised by Facility staff at the time of the March 21 Incident. On May 2, 2010, Resident #1 was involved in an altercation with another resident of the Facility, Resident #5 (May 2 Incident). The Health Form that was completed in conjunction with Resident #5's admission to the Facility reflected that he was a five-foot, eight-inch, 289 pound man, with a history of chronic obstructive pulmonary disease, coronary artery disease, atherosclerotic heart disease, diabetes mellitus, morbid obesity, dilated cardiomyopathy, and kidney failure. The May 2 Incident and its aftermath were accurately documented by Facility staff by an entry written in Spanish on the Facility's Daily Communication Log for that date (May 2 Daily Communication Log). The following is the English translation of that entry:11 At midnight [Resident #5], [Resident #1] and [E. S.] were in the nurses' station happily chatting. All of a sudden, [Resident #1] verbally insulted [Resident #5] without any reason whatsoever.[12] Offended, [Resident #5] got up from his chair,[13] and [Resident #1] pushed his chest.[14] [Resident #5] called the police--while the police were on their way, [Resident #5] thought about what had happened and did not want to do anything improper, but at the same time he was worried about his safety because he had heard that [Resident #1] has a knife in his room.[15] [Resident #5] asked my opinion and I suggested that he tell the office about it, that you would resolve the problem in the best possible way and that he shouldn't file a report against [Resident #1], and [Resident #5] made his own decision to not have the police take [Resident #1] away. [Resident #1] had not always behaved this way, he was not acting normally. Ms. [E.] disappeared for over half an hour and since I know that she and Mr. [R.] are good friends I asked him about her. [Resident #1] heard me and made a show of the matter, he took charge of the matter as if he were the boss. Without my realizing it, he sent [E.] outside to look for [Ms. E.] and there is no reason for him to do my job. [Ms. E.] was in the back part of Munne accompanied by Mr. [N.]. I had already gone back there in the dark calling out to [Ms. E.] by name and [she] heard me but did not answer that she was there. If she had answered me I wouldn't have worried any more. When I looked at her I asked her: Did you hear that I was looking for you? And she answered that she had. The problem is that [Resident #1] is taking on a role that does not correspond to him, on top of a poor attitude; there was no need for these incidents. [I was] [t]rying to keep the other residents from realizing what was going on so that they would not get riled up and to avoid an even bigger commotion. This entry on the May 2 Daily Communication Log constitutes the only record evidence concerning the May 2 Incident. The record evidence is silent as to the extent to which Resident #1, Resident #5, and the other residents of the Facility were being supervised by Facility staff at the time of the May 2 Incident. On May 10, 2010, while he still was a resident of the Facility, Resident #5 was "punched"16 (May 10 Incident) and, as a result, sustained an injury (a two-centimeter laceration above his right eyebrow) for which he was taken to Larkin Community Hospital's emergency room for treatment. After receiving five stitches to close the laceration, he was discharged from the hospital. Other than the "[h]ospital [r]ecord[]" entry17 memorializing the statement made by Resident #5 to emergency room staff concerning his having been "punched" by an unidentified assailant,18 there is no record evidence as to what happened during the May 10 Incident. The record evidence is silent as to the extent to which Resident #5 and the other residents of the Facility, including Resident #1, were being supervised by Facility staff at the time of the May 10 Incident.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is hereby RECOMMENDED that the Agency for Health Care Administration issue a Final Order dismissing the Amended Administrative Complaint. DONE AND ENTERED this 9th day of June, 2011, in Tallahassee, Leon County, Florida. S STUART M. LERNER 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 June, 2011.
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.
