Nursing Home and Assisted Living Facility: Adverse Incidents And Notices of Intent. Report to the Legislature July 2008 Status Report

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1 Nursing Home and Assisted Living Facility: Adverse Incidents And Notices of Intent Report to the Legislature July 2008 Status Report July 31, 2008

2 TABLE OF CONTENTS SUBJECT PAGE Summary 4 Facility Report Descriptions and Requirements 4 Agency Review 5 Adverse Incident Data Summary 6 Total Number of Adverse Incidents Received Over Time (Table 1) 6 Total Number of Adverse Incidents by (Table 2) 7 Top Five Nursing Home Outcomes Over Time (Table 3) 8 Top Five Assisted Living Facility Outcomes Over Time (Table 4) 9 Nursing Home Adverse Incident Outcomes by Type (Table 5) 9 Assisted Living Facility Adverse Incident Outcomes by Type (Table 6) 11 Adverse Incident Inspections 12 Adverse Incident Inspections by (Table 7) 13 Medical Quality Assurance 13 Nursing Home and Assisted Living Facility Adverse Incidents: Practitioner Actions Over Time (Table 8) Nursing Home and Assisted Living Facility Adverse Incidents: Action Taken Against Involved Practitioners (Table 8a) Total Number of Nursing Home Notices of Intent Received by the Agency (Table 9) Total Number of Assisted Living Facility Notices of Intent Received by the Agency (Table 10) Total Number of Nursing Home Notices of Intent Received by the Agency (by Over Time) (Table 11)

3 TABLE OF CONTENTS SUBJECT Total Number of Assisted Living Facility Notices of Intent Received by the Agency (by Over Time) (Table 12) PAGE 18 Nursing Home Notices of Intent by Type (Table 13) 19 Assisted Living Facility Notices of Intent by Type (Table 14) 20 3

4 T Nursing Home and Assisted Living Facility: Adverse Incidents e Agency for Health Care Administration e for all for Health Care Administration champions accessible, affordable, quality health July 2008 Summary This is the seventh report to the Legislature on nursing home and assisted living facility adverse incidents. Data presented in this report are based on the date the adverse incident and liability claim reports were received by the Agency during a fiscal year. Data presented in the report include: July 1, 2007 to June 30, 2008 o 3,928 reported adverse incidents occurring with associated outcomes. o 17 on-site visits to nursing homes and 12 on-site visits to assisted living facilities specifically in response to adverse incidents requiring investigations. These surveys did not result in findings of Class I & II deficiencies. o 70 practitioner cases opened by the Department of Health in response to adverse incident reports resulting in 33 license revocations or suspensions. Comments o Adverse incident and liability claim information currently available is self-reported and is not subject to verification or audit. o All data reported are based upon the information received by the Agency from nursing homes and assisted living facilities unless otherwise indicated. o Counties are not included in tables if no information has been reported. Facility Reports Report Descriptions and Requirements Adverse Incidents Adverse incidents are those events over which facility staff or personnel could exercise control, rather than occurring as a result of the resident s condition, that resulted in: 4

5 Death; Brain or spinal damage; Permanent disfigurement; Fracture or dislocation of bones or joints; A limitation of neurological, physical, or sensory function; Requiring medical attention to which the resident has not given his or her informed consent including failure to honor advanced directives; and/or A transfer of the resident, within or outside the facility, to a unit providing a more acute level of care. Or any event (regardless of facility control) that resulted in: Abuse, neglect, or exploitation; Resident elopement; and/or A report to law enforcement. When an incident occurs, nursing homes are required to notify the facility risk manager within three (3) business days of the occurrence and notify the Agency within one (1) business day after the risk manager receives the report. Assisted living facilities must notify the Agency within one (1) business day of the occurrence of the incident. The Agency is authorized to investigate any such incident and may prescribe measures that must or may be taken in response to the incident. Nursing homes must submit a complete adverse incident report to the Agency for each adverse incident within 15 calendar days of the occurrence. Assisted living facilities must submit a complete adverse incident report to the Agency for each adverse incident within 15 days of the occurrence. The reporting facility also indicates if the incident was determined to be an adverse incident. By law, the adverse incident report is confidential and is not discoverable or admissible in any civil or administrative action, except in disciplinary proceedings by the Agency or the appropriate regulatory board. Notices of Intent Generally, a Notice of Intent (NOI) serves to notify the facility of a plaintiff s intent to sue for some cause of action. Nursing homes and assisted living facilities are required to provide the name of the resident, the date of the incident, if applicable, and the type of injury or violation. Facilities have been instructed to submit this information to the Agency by the 10 th of the month following the month a NOI is received. Agency Review All adverse incident reports are reviewed to determine if further Agency action is necessary. An investigation may be requested based on quality of care concerns involving specific residents or a situation may exist that could cause harm to one or more residents. Information submitted in 5

6 an adverse incident report may also trigger a request for investigation of another licensed facility if there is concern regarding care received at another licensed provider. All adverse incident reports are made available to the Department of Health. Adverse Incident Data Summary Table 1 shows a comparison of the number of adverse incidents received statewide for both nursing homes and assisted living facilities over the past seven fiscal years. Table 2 details the number of adverse incidents by facility type and by county of facility location for the period July 1, 2007 through June 30, Table 1: Total Number of Adverse Incidents Received Over Time Assisted Living Facilities Nursing Homes

7 Table 2: Total Number of Adverse Incidents by July 1, 2007 through June 30, 2008 # Nursing Home Incidents # Nursing Home Incidents # ALF # ALF Incidents Incidents Alachua 36 9 Lake Baker 6 0 Lee Bay Leon Bradford 10 1 Levy 1 6 Brevard Madison 7 0 Broward Manatee Calhoun 1 0 Marion Charlotte Martin 12 7 Citrus Monroe 22 0 Clay 17 4 Nassau 8 4 Collier Okaloosa Columbia 11 9 Okeechobee 1 0 Dade Orange Desoto 0 3 Osceola Dixie 1 0 Palm Beach Duval Pasco Escambia Pinellas Flagler 3 5 Polk Gadsden 1 0 Putnam 9 14 Gilchrist 6 0 Santa Rosa 9 3 Gulf 3 0 Sarasota Hamilton 0 3 Seminole Hardee 3 0 St. Johns Hendry 18 3 St. Lucie Hernando Sumter 3 1 Highlands Suwannee 4 1 Hillsborough Taylor 5 0 Holmes 7 0 Volusia Indian River Wakulla 3 0 Jackson 10 1 Walton 1 0 Jefferson 4 0 Washington 4 7 Lafayette 16 0 Total 2,090 1,838 *Counties are not included in the table if no adverse incidents were reported. 7

8 Outcomes The top five types of adverse incident outcomes reported by nursing homes during the period July 1, 2007 through June 30, 2008, are: transfer to a higher acuity level facility, abuse, neglect or exploitation, fracture/dislocation, report to law enforcement, and elopement. For assisted living facilities, the top five adverse incident outcomes reported for the same period of time are: transfer to a higher acuity level facility, fracture/dislocation, report to law enforcement, elopement, and abuse, neglect or exploitation. An adverse incident may have more than one outcome; thus, the numbers of outcomes will exceed the numbers of adverse incidents. Tables 3 and 4 show a comparison of the top five outcomes over the last seven fiscal years. Tables 5 and 6 detail the number of incident outcomes by facility type by county for the period July 1, 2007 though June 30, Table 3: Top Five Nursing Home Outcomes Over Time Transfer Fracture Abuse/Neglect Elopement Law Enforcement

9 1800 Table 4: Top Five Assisted Living Facility Outcomes Over Time Transfer Fracture Abuse/Neglect Elopement Law Enforcement Table 5: Nursing Home Adverse Incident Outcomes by Type July 1, 2007 through June 30, 2008 (An incident may have one or more outcomes) Death Brain/ Spine Disfigure Fracture Limit Function No Consent Transfer Abuse/ Neglect Elope Law Enforce Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade

10 Table 5 Cont d: Nursing Home Adverse Incident Outcomes by Type July 1, 2007 through June 30, 2008 (An incident may have one or more outcomes) Death Brain/ Spine Disfigure Fracture Limit Function No Consent Transfer Abuse/ Neglect Elope Law Enforce Dixie Duval Escambia Flagler Gadsden Gilchrist Gulf Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns

11 Table 5 Cont d: Nursing Home Adverse Incident Outcomes by Type July 1, 2007 through June 30, 2008 (An incident may have one or more outcomes) Death Brain/ Spine Disfigure Fracture Limit Function No Consent Transfer Abuse/ Neglect Elope Law Enforce St. Lucie Sumter Suwannee Taylor Volusia Wakulla Walton Washington Total *Counties are not included in the table if no outcomes were reported. Table 6: Assisted Living Facility Adverse Incident Outcomes by Type July 1, 2007 through June 30, 2008 (An incident may have one or more outcomes) Death Brain/ Spinal Disfigure Fracture No Consent Transfer Abuse/ Neglect Law Enforce Elope Alachua Bay Bradford Brevard Broward Charlotte Citrus Clay Collier Columbia Dade Desoto Duval Escambia Flagler Hamilton Hendry Hernando Highlands Hillsborough Indian River Jackson Lake

12 Table 6 Cont'd: Assisted Living Facility Adverse Incident Outcomes by Type July 1, 2007 through June 30, 2008 (An incident may have one or more outcomes) Death Brain/ Spinal Disfigure Fracture No Consent Transfer Abuse/ Neglect Law Enforce Elope Lee Leon Levy Manatee Marion Martin Nassau Okaloosa Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole Sumter St. Johns St. Lucie Suwannee Volusia Washington Total *Counties are not included in the table if no outcomes were reported. Adverse Incident Inspections If review of an adverse incident raises concerns about resident safety, an adverse incident inspection is initiated. If deficiencies are found, a classification is made based on the severity of the deficiency. Class I deficiencies are those that cause or have the potential to cause serious injury, harm, impairment or death to a resident. Class II deficiencies result in negative outcomes that compromise residents abilities to maintain or attain their highest practicable functional levels. Class III deficiencies result in no more than minimal physical, mental or psychological discomfort to a resident or have the potential to compromise the resident s ability to maintain or reach his/her highest practicable functional level. Class IV deficiencies have no more than a minor negative impact on the resident. There were no Class I or Class II deficiencies cited as a result of an adverse incident investigation for the period July 1, 2007 through June 30,

13 Table 7 details the number of nursing home and assisted living facility inspections completed as a result of an adverse incident listed by facility type, county and the number of times deficiencies were cited. Table 7: Adverse Incident Inspections by July 1, 2007 through June 30, 2008* # Of Completed Inspections # With Deficiencies # Of Completed Inspections # With Deficiencies NH ALF NH ALF NH ALF NH ALF Broward Marion Charlotte Orange Clay Pasco Duval Pinellas Highlands Polk Hillsborough Putnam Indian River Seminole Lee Volusia Grand Total *Counties not listed did not have any adverse incident inspections. Medical Quality Assurance Between July 1, 2007 and June 30, 2008, the Consumer Services Unit of the Department of Health reviewed nursing home and assisted living facility adverse incidents and combined duplicative information to create 11,535 case number entries. Of these entries, 440 involving practitioners were investigated. Table 8 shows nursing home and assisted living facility practitioner actions over time. Table 8a details actions taken against involved practitioners. As a result of information discovered during these investigations, there were 70 findings of probable cause and 33 license revocations or suspensions. Of the 33 revocations or suspensions, 27 involved certified nursing assistants and 6 involved licensed nurses. Table 8: Nursing Home and Assisted Living Facility Adverse Incidents Practitioner Actions Over Time Investigated Probable Cause Revocations or Suspensions

14 Table 8a: Nursing Home and Assisted Living Facility Adverse Incidents: Action Taken Against Involved Practitioners * 7/1/2007-6/30/2008 Total Referred for Probable Suspension/ Reviewed Investigation Cause Revocation Nursing Homes Certified Nursing Assistants 1, Dentistry Medicine Nursing Nursing Home Administrators Occupational Therapy Physical Therapy Radiologic Technology Respiratory Care Speech-Language Pathology Non-Jurisdictional** 5, Subtotal 7, Assisted Living Certified Nursing Assistants Facilities Nursing Non-Jurisdictional** 4, Subtotal 4, Total 11, * Data provided by Department of Health; Consumer Services Unit. **Non-Jurisdictional indicates there is either no identified licensed subject or incidents would not result in practitioner regulatory or statutory infractions punishable by the regulatory boards under the Department of Health. Notices of Intent Nursing Homes and Assisted Living Facilities Between July 1, 2007 and June 30, 2008, the Agency received 357 nursing home NOI reports and 22 assisted living facility NOI reports from the facilities and plaintiff s attorneys. Tables 9 and 10 detail the number of NOIs received by calendar quarter. 14

15 Table 9: Total Number of Nursing Home Notices of Intent Received by the Agency Qtr 1 (Jul-Sep) Qtr 2 (Oct-Dec) Qtr 3 (Jan-Mar) Qtr 4 (Apr-Jun) Table 10: Total Number of Assisted Living Facility Notices of Intent Received by the Agency Qtr 1 (Jul-Sep) Qtr 2 (Oct-Dec) Qtr 3 (Jan-Mar) Qtr 4 (Apr-Jun)

16 Tables 11 and 12 show a comparison of the number of Notices of Intent received by the Agency from nursing homes and assisted living facilities over the last seven fiscal years. Counties are not included in tables if no information has been reported. Table 11: Total Number of Nursing Home Notices of Intent Received by the Agency (by Over Time) Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade Desoto Duval Escambia Flagler Franklin Gadsden Gilchrist Gulf Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee

17 Table 11 Cont d: Total Number of Nursing Home Notices of Intent Received by the Agency (by Over Time) Leon Levy Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Volusia Wakulla Walton Total 1, Grand Total 4,422 17

18 Table 12: Total Number of Assisted Living Facility Notices of Intent Received by the Agency (by Over Time) Alachua Brevard Broward Charlotte Citrus Collier Columbia Dade Duval Escambia Flagler Hernando Highlands Hillsborough Indian River Lake Lee Leon Manatee Marion Martin Nassau Orange Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Volusia Total Grand Total

19 Type of Injury Facilities are asked to identify the type of resident injury that is specified in each Notice of Intent received and reported to the Agency. In some cases, providers do not identify a type of injury and in some cases they indicate multiple injury types. For nursing homes, the top five types of injuries identified that are associated with NOI for fiscal year are: other, falls, pressure ulcers, abuse and fracture. For assisted living facilities, the top types of injuries identified on the NOI are: other, fracture, abuse/neglect, law enforcement and death. Tables 13 and 14 provide the number of reported nursing home and assisted living facility Notices of Intent by county by type of injury alleged. Counties are not included in tables if no information has been reported. Table 13: Nursing Home Notices of Intent by Type July 1, 2007 through June 30, 2008 (A Notice of Intent may have one or more types.) Brain Dis- Frac- Funct Abuse/ Law Psr Drug Wt Death /Spinal figure ture Limit Neglect Elope Enforce Other Ulcer Restrain Error Loss Falls Alachua Bay Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade Duval Escambia Flagler Gadsden Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Madison

20 Table 13 Cont d: Nursing Home Notices of Intent by Type July 1, 2007 through June 30, 2008 (A Notice of Intent may have one or more types.) Brain Dis- Frac- Funct Abuse/ Law Psr Drug Wt Death /Spinal figure ture Limit Neglect Elope Enforce Other Ulcer Restrain Error Loss Falls Manatee Marion Martin Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Sarasota Seminole St. Johns St. Lucie Suwannee Taylor Volusia Total Table 14: Assisted Living Facility Notices of Intent by Type July 1, 2007 through June 30, 2008 (A Notice of Intent may have one or more types.) Death Brain /Spinal Disfigure Fracture No Consent Abuse/ Neglect Elope Law Enforce Broward Dade Duval Hillsborough Leon Manatee Orange Palm Beach Pasco Pinellas Sarasota Volusia Total Other 20

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