Department of Health and Human Services DEPARTMENTAL APPEALS BOARD Civil Remedies Division |
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IN THE CASE OF | |
Southridge Nursing and Rehabilitation Center, |
DATE: February 23, 2001 |
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Health Care Financing Administration
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Docket No.C-98-134
Decision No. CR744 |
DECISION | |
I decide that on October 4 and 5, 1997, Southridge
Nursing and Rehabilitation Center (Petitioner) was not in substantial compliance
with one of the two Medicare participation requirements for which it was
cited by the Health Care Financing Administration (HCFA), specifically 42
C.F.R. § 483.25(h)(2). Accordingly, HCFA was authorized to impose a civil
money penalty (CMP). HCFA's determination that Petitioner's noncompliance
was at an immediate jeopardy level was not clearly erroneous. Because of
the immediate jeopardy finding, applicable to a situation affecting one
resident for two days, $6,100 is a reasonable CMP. I. Procedural background HCFA found that Petitioner was not in substantial compliance
with Medicare participation requirements on October 4-5, 1997, based on
the October 10, 1997 complaint survey by the Iowa Department of Inspections
& Appeals (IDIA).(1) A survey is identified
by its exit date; the survey lasted from October 7 through October 10,
1997. HCFA cited Petitioner under Tag F-324 and Tag F-490. HCFA
determined that there was immediate jeopardy for each of the citations;
each was cited at a "J" level of scope and severity. HCFA imposed a $6,100
CMP, comprised of $3,050 per day for two days of immediate jeopardy on
October 4-5, 1997. Petitioner was found by HCFA to be in substantial compliance
with Medicare participation requirements beginning October 6, 1997. During the hearing, on June 6-7, 2000, in Des Moines and Marshalltown, Iowa, respectively, each party called witnesses to testify. The transcript of the hearing is referred to as "Tr." At the hearing, Petitioner's exhibits (P. Exs.) 1-8 were admitted into evidence without objection. Tr. 11. HCFA's exhibits (HCFA Exs.) 1-3 were offered into evidence, but Petitioner objected to HCFA Ex. 3. I overruled the objection, and HCFA Exs. 1- 3 were admitted into evidence. Tr. 10. At the close of the hearing, the parties jointly offered HCFA Ex. 4 as an additional exhibit which I admitted. Tr. 43. The parties submitted initial posthearing briefs (P. Br. and HCFA Br.) and reply briefs (P. R. Br. and HCFA R. Br.).
II. Applicable law Skilled nursing facilities, such as Petitioner, participate
in the Medicare program by entering into provider agreements with the
United States Department of Health and Human Services (DHHS). Requirements
of participation are imposed by statute and regulation. Act, section 1819
[42 U.S.C. § 1395i-3]; 42 C.F.R. Parts 483, 488, and 489. The regulations define "substantial compliance" as follows:
"Substantial compliance means a level of compliance with the
requirements of participation such that any identified deficiencies pose
no greater risk to resident health or safety than the potential for causing
minimal harm." 42 C.F.R. § 488.301 (italics in original). The regulations define "immediate jeopardy" as follows:
"Immediate jeopardy means a situation in which the provider's
noncompliance with one or more requirements of participation has caused,
or is likely to cause, serious injury, harm, impairment, or death to a
resident." Id. (italics in original). The regulations specify that a CMP that is imposed against
a provider will fall into one of two broad ranges of penalties. Per day
CMPs in the lower range, from $50 to $3,000 per day, are imposed for deficiencies
that do not constitute immediate jeopardy, but either cause actual harm
to residents, or cause no actual harm, but have the potential for causing
more than minimal harm. Per day CMPs in the upper range, from $3,050 per
day to $10,000 per day, are imposed for deficiencies that constitute immediate
jeopardy to one or more of a provider's residents. 42 C.F.R. §§ 488.408,
488.438(a). The preponderance of the evidence standard is applied
to resolve disputed issues of fact, except as provided by 42 C.F.R. §
498.60(c)(2), which states that in CMP cases, HCFA's determination as
to the level of noncompliance of [a skilled nursing facility] must be
upheld unless it is clearly erroneous. HCFA bears the burden of coming forward with evidence
sufficient to establish a prima facie case that the provider was not in
substantial compliance with the participation requirements at issue. Once
HCFA has established a prima facie case, the provider has the ultimate
burden of persuasion: to prevail, the provider must prove by a preponderance
of the evidence that it was in substantial compliance with each participation
requirement at issue. Hillman Rehabilitation Center, DAB No. 1611
(1997); aff'd Hillman Rehabilitation Center v. United States,
No. 98-3789 (GEB) (D.N.J. May 13, 1999). III. Issues, findings of fact and conclusions of law
The principal issue is whether Petitioner was in substantial compliance with Medicare participation requirements on October 4 and 5, 1997. The more specific issues are:
Below, I make four findings of fact and conclusions of
law (Findings). I set forth each Finding as a separately numbered heading
in bold face type, followed by a discussion of the Finding in detail.
The first two Findings cover the two citations on the Statement of Deficiencies,
HCFA form 2567L, specifically, 42 C.F.R. §§ 483.25(h)(2) and 483.75, Tags
F-324 and F-490, respectively. The third Finding covers HCFA's determination
that there was immediate jeopardy, which must be upheld unless clearly
erroneous, under 42 C.F.R. § 498.60(c)(2). The fourth Finding covers the
reasonableness of the CMP.
Following the October 10, 1997 survey, HCFA cited Petitioner with Tag F-324, the quality of care requirement under 42 C.F.R. § 483.25(h)(2), which states in pertinent part:
I find that HCFA's allegation that Petitioner failed to
provide "adequate supervision" is sustained by the evidence.
Petitioner is a 82-bed skilled nursing facility, sometimes
called a "SNF," sometimes called a nursing home, located in Marshalltown,
Iowa. There were 68 residents during the month of October 1997. HCFA Ex.
1. Resident # 3 was a 41-year-old male resident of Petitioner's
facility who had been diagnosed with multiple sclerosis (MS). Tr. 54.
He functioned at a high-cognitive level. Tr. 33-34. He was assessed on
the Minimum Data Set (MDS) documentation as having no deficits with respect
to cognitive decision-making. HCFA Ex. 2 at 99. He testified at the hearing.
Tr. 193-205. He utilized an electric wheelchair for self-mobility. His
Plan of Care (POC) showed him with no mental deficits and provided him
with control over his medical decisions. HCFA Ex. 2 at 118; HCFA Ex. 4
(item c); Tr. 57, 103, 221-222. The POC did not restrict his activities.
Resident # 3 owned and used a computer located in his room. HCFA Ex. 2
at 10; Tr. 171. On October 4, 1997, Resident # 3 utilized his electric
wheelchair to transport himself outside of Petitioner's building. HCFA
Ex. 4 (item d); Tr. 194. He traveled East of Petitioner's building to
a common area known as the picnic table. HCFA Ex. 2 at 12; Tr. 172-173.
He performed this maneuver several times a day to go outside to smoke
cigarettes. He did not utilize Petitioner's written sign-out procedure
for these occasions. He did not have a habit of leaving the facility with
family or friends without signing out (others signed for him due to his
loss of writing ability). HCFA Ex. 2 at 110; Tr. 202. In the early evening of October 4, 1997, members of Petitioner's
staff last observed Resident # 3 near the picnic table visiting with his
father at approximately 7:20 p.m. HCFA Ex. 4 (item e); Tr. 186. Later,
Resident # 3 decided to venture further, beyond the picnic table area.
Without informing anyone what he was doing or where he was going, he guided
his wheelchair outside the chain-link fence surrounding the perimeter
of the Northeast side of the facility. HCFA Ex. 1 at 2; HCFA Ex. 2 at
33; Tr. 195. He testified that he wanted to get a better look at the new
construction taking place on the Northeast side of Petitioner's facility.
Tr. 194. The topography on the outside of the chain-link fence included
a downward slope of about 30 degrees, away from the fence toward a lower
weedy area. Resident # 3 maneuvered along the outside of the fence. When
he tried to back the chair up to return to the facility, he got too close
to the edge of the hill. The wheelchair could not overcome the gravity
of the slope. His wheelchair, with him in it, careened down the slope
for approximately 23 feet to the weedy flat area. Id. Resident
# 3 utilized a seatbelt in his wheelchair. He neither upset nor fell out
of the chair. He maneuvered the self-propelled wheelchair an additional
25 feet on the flat area. Resident # 3 estimated that he went down the hill about
8:00 p.m. After a time, he lowered himself out of his wheelchair to the
ground and into the weeds. He estimated that this occurred at approximately
9:00 p.m. Resident # 3 indicated that it was dark at the time he lowered
himself out of the wheelchair. Tr. 195. Resident # 3 said he initially
called out for help, but due to a pre-existing condition of laryngeal
spasticity, he could not be heard. HCFA Ex. 4 (item c); Tr. 194. He indicated
that he had a few leg spasms before he laid down in the weeds, but indicated,
"that was not unusual. Not at all." Tr. 196. After he lowered himself
from the wheelchair he had no further cramps the remainder of the night
or the next morning. Tr. 92, 196-197. He further indicated that he had
no pain or discomfort lying on the grass. Tr. 200-201. He testified that
it was a little cold. He went to sleep and slept soundly. Tr. 179, 196, 200.
He believed that he fell asleep fairly quickly. Tr. 197. He didn't hear
anyone calling for him. Tr. 197, 201. He didn't see any flashlights. Tr.
201. He awakened twice during the night to change his catheter bag and
empty urine. The temperature the evening of October 4, 1997 reached a
low of 57 degrees. HCFA Ex. 4 (item m). It did not rain or snow the evening
of October 4, 1997. HCFA Ex. 4 (item n). He did not otherwise awaken until
dawn, when he was found by Petitioner's administrator at 6:30 a.m. When
he awoke at dawn, he looked up and saw his father, the administrator,
and facility employees. Tr. 196. Resident # 3 was then brought inside
and thoroughly assessed. He suffered no harm and was jovial about the
incident. HCFA Ex. 4 (item q); Tr. 38, 177-179, 198. At the hearing, he
described his experience as being like a "camping trip." Tr. 194. The Charge Nurse was working a double shift, from 2:00
p.m. to 10:00 p.m. October 4, 1997 and from 10:00 p.m. October 4 to 6:00
a.m. October 5, 1997. HCFA Ex. 2 at 34-35. While Resident # 3 was outside
lying in the weeds that evening at a time that he was normally in his
room and ready to be put to bed, he could not be located. He was not found
in his room at 9:00 p.m. for his usual medications. HCFA Ex. 2 at 75A.
The nursing staff reported to the Charge Nurse at approximately 9:30 p.m.
that Resident # 3 could not be found. HCFA Ex. 4 (item f). The Charge
Nurse, along with others, made a thorough search of the interior of Petitioner's
facility as well as the outside picnic area. HCFA Ex. 4 (item f). The Charge Nurse along with Nurse Kathleen M. together
made a search of the facility building and grounds with flashlights and
called out Resident # 3's name at 9:30 p.m. on October 4 and again at
12:30 a.m. on October 5, but could not find him. HCFA Ex. 4 (items f and
h). The first time the Resident sign-out book was checked for Resident
# 3's name was stated to be 12:30 a.m. HCFA Ex. 2 at 21. The Charge Nurse did not pursue the "Missing Resident"(2)
procedure. She stated she believed that the missing resident was with
family members or friends. HCFA 2 at 3. The facility had a "Missing Resident"
procedure which was in effect, accessible to the staff, and the staff
had been informed of its content. HCFA Ex. 2 at 131-132. The Charge Nurse
acknowledged receiving training that covered the "Missing Resident" policy
on December 23, 1996. The Orientation Skills Checklist, which the Charge
Nurse initialed, included item (14) "Missing Resident Policy." HCFA Ex.
2 at 30. Petitioner's employees, Kathy M., Dan O., Anna B., Cindy B.,and
Greg G. recall seeing the "Missing Resident" policy in its usual place
on the bulletin board prior to October 4, 1997. The statement of each
of those employees is found in HCFA Ex. 2 at 5, 11, 13, 14, and 20, respectively.
Telephone calls were placed to the home of Resident #
3's mother and sister between 10:15 and 10:30 p.m. on October 4 to inquire
if Resident # 3 was with family or friends. HCFA Ex. 2 at 6. But no one
answered the calls. Resident # 3's mother and sister were both listed
on the clinical record as contact persons for him. HCFA Ex. 4 (item g).
Some calls were again made to family members at 2:30 a.m. and at 4:00
a.m. on October 5, 1997, but again no one answered the phone. HCFA Ex.
4 (item i). The clinical record for Resident # 3 did not list a phone
number for Resident # 3's father, who was divorced from Resident # 3's
mother. Tr. 187. The Charge Nurse called the Marshalltown police at approximately
4:45 a.m. HCFA Ex. 2 at 8; HCFA Ex. 4 (item j). A police officer, Officer
McCauley, arrived and took a missing person report at approximately 5:00
a.m. The officer then conducted a sweep of the area outside North and
East of Petitioner's facility for approximately 45 minutes with his flashlight
while with the Charge Nurse. Tr. 157. He continued to search by himself
with his flashlight. He estimated he ceased his search at around 6:30
a.m. Tr. 157-158. The officer testified that he conducted a thorough search.
Tr. 166. He made several passes in a semi-circle extending out ten to
twenty yards on each pass, making a total of seven to eight passes. Tr.
162. Officer McCauley concluded that Resident # 3 was not in the field
behind the facility. Tr. 158. He found neither Resident # 3 nor his wheelchair. A call was made at approximately 5:30 a.m. to the Director
of Nursing (DON) who was home sleeping. HCFA Ex. 4 (item k); Tr. 176,
188. The DON then promptly called the facility administrator who was also
at home. When the administrator arrived, he began yet another search of
the area outside of the chain-link fence. It was now dawn. The administrator
found Resident # 3 asleep in the weeds at 6:30 a.m. HCFA Ex. 4 (item p).
When awakened, Resident # 3 was initially assessed where he was found
and then brought inside Petitioner's building. Resident # 3 was then given a complete physical where
it was again confirmed he suffered no injuries. Resident # 3's treating
physician was contacted but Resident # 3 required no physician intervention,
no medications, no diagnostic tests or medical treatments or hospitalization
as a result of being outdoors overnight. HCFA Ex. 4 (items r & s). The Charge Nurse was fired on October 5, 1997 for "gross incompetence - knowingly did not follow proper procedure for missing resident." She had failed to contact the administrator and the DON pursuant to Petitioner's policy regarding missing residents. HCFA Ex. 2 at 26; HCFA Ex. 4 (item l). The policy requires that the first step be notifying the administrator that a resident is missing. HCFA Ex. 2 at 131. On October 6, 1997, the administrator made a report of the missing resident to the IDIA. HCFA Ex. 2 at 55, 62.Surveyor M. TenEick personally observed Resident # 3 unclothed on October 7, 1997 and "saw nothing wrong with him." HCFA Ex. 2 at 69; Tr. 38, 92-93. She further acknowledged that Resident # 3 did not suffer any serious physical harm from being outside. Tr. 39. Resident # 3 testified that he also suffered no psychological harm. Resident # 3 was asked if the ride down was scary, frightening? He testified, "it was quick." Tr. 199.
Where the adjective "adequate" modifies the noun "supervision" (of residents), "adequate" has been used variously as a requirement of "quantity" (as a synonym for sufficiency of numbers) and of "quality." See Woodstock Care Center, DAB No. 1726 (2000) and Lakeland Continuing Care Center, DAB CR683 (2000).
When being considered as a quantity requirement, this
regulation also interfaces with the content and purposes of Resident #
3's assessment and plan of care in the Nursing services regulation.
In this case, there is no showing that a greater number
of on-duty nursing staff would have prevented the incident. There is also
no showing that an increase in the numbers of nursing staff or a different
ratio of staff to residents on the night shift would have affected the
outcome of the location and recovery of Resident # 3 or would have resulted
in a technically better search (although common sense could lead to the
inference that it would have).
Resident # 3 functioned at a high-cognitive level and
made his own decisions and was actively involved in his own care. He was
assessed on the MDS assessment as having no deficits with respect to cognitive
decision-making. Because of his control of his cognitive functions and
his independence, there is no dispute that this resident had greater freedom
of movement and a higher level of trust (not to injure himself) than the
remainder of Petitioner's residents. Because of his freedom of movement,
he could have easily put himself into a position of danger many times
before Petitioner's staff could have had an opportunity to intervene or
rescue him. He had the freedom to leave the interior of Petitioner's building
any time he wished, but there is no history that he had abused that privilege.
Petitioner presented evidence that giving Resident # 3 more freedom over
his own movement was important to his attaining his highest practicable
level of physical and mental and psycho social well-being. Tr. 58. HCFA has not asked that Petitioner keep Resident # 3 indoors
at all times. The regulation cited by HCFA, 42 C.F.R. § 483.25, states
very clearly that Petitioner must provide services, including supervision,
which would allow the resident to attain and maintain his highest practicable
level of physical, mental, and psycho social well-being. However, because
Resident # 3 was physically dependent, Petitioner had a countervailing
duty to protect the dependent individual under its care against accidents.
This would involve consideration of a variety of measures designed to
keep staff reasonably apprised of his needs. The adequacy of measures
which it takes to effectuate this requirement does place a high expectation
on Petitioner to achieve results, but it does not amount to strict liability
or require absolute success in an obviously difficult task. Woodstock,
supra, at 27. While 42 C.F.R. § 483.25(h)(2) does not impose strict
liability upon Petitioner, for instance where a resident wanders unsupervised,
the relevant inquiry is whether there was supervision which was adequate
for Resident # 3's situation. Heath Nursing and Convalescent Center,
DAB CR623 at 6 (1999). By the time Resident # 3 was determined to be missing
(9:00-9:30 p.m.), the wheelchair had already rolled down the embankment,
it was dark, and Resident # 3 had lowered himself to the ground into the
weeds and possibly was already asleep. Tr. 197. I find that Petitioner
is not responsible for Resident # 3 rolling down the hill, even though
that may have been the time of the greatest potential for injury to Resident
# 3. I find that Petitioner could not have anticipated that event and
had no control over it. Consequently, Resident # 3's having rolled down
the hill was not the result of any lack of adequate supervision by Petitioner.
[To prevent the occurrence of a similar incident, however, precautions
may be required.] From the area outside the chain-link fence at the top
of the slope, one could view the new building construction site, which
was adjacent to the weeds at the bottom of the slope. The construction
site could be accessed from directions other than that of Resident # 3's
approach. There was no evidence that Petitioner should have sealed off
the area beyond the chain-link fence to prevent ingress or egress except
by designated routes. HCFA Ex. 2 at 53-54. Petitioner's not having blocked
access to the area outside of Petitioner's chain-link fence did not, in
this case, contribute to a lack of adequate supervision by Petitioner. Petitioner's facility was located in an uncongested neighborhood
in a relatively small town within a rural community, not inherently dangerous.
The area where Resident # 3 rolled downhill also was not in any ordinary
sense dangerous. The slope was gradual. There were no hidden holes. There
were no rocks. There was a soft surface (i.e., grass) to traverse. There
were no physical factors suggesting that there was any duty to warn of
physical danger. When asked whether his ride down the hill was "scary,
frightening," he answered: "it was quick." Tr. 199. I find that Petitioner's
not having warned any of the residents of any potential danger of the
embankment outside the chain-link fence did not, in this case, contribute
to a lack of adequate supervision by Petitioner. The Charge Nurse knew as early as 9:30 p.m. on October
4, 1997 that Resident # 3 was missing. The nursing assistant attending
to Resident # 3 did not find him for his evening medications at 9:00 p.m.
or to put him to bed and reported this to the Charge Nurse. There was
no indication of an irregularity related to Resident # 3 between 7:20
and 9:30 p.m. October 4, 1997, which would have suggested to the Charge
Nurse that she should promptly implement the Missing Resident procedure.
I find that the failure to consider the Missing Resident procedure earlier
than 9:30 p.m. on the evening of October 4, 1997 did not contribute to
a lack of adequate supervision by Petitioner. There was testimony that the Missing Resident policy was
not in its usual posted place on the evening when Resident # 3 was missing.
Even if the document was not in its usual place or was lost, it is not
credible that the Charge Nurse did not know of its existence, since she
and all the other staff had received in-service training. She acknowledged
that she received orientation in the policy. HCFA Ex. 2 at 30 item (14).
After reasonable persons could have concluded that there was the possibility
of a missing resident (Resident # 3), the carefully thought out policies,
procedures, and protocol needed to be considered. The plan was prepared
by Petitioner and was presumably tailored to reflect the needs of the
residents in the particular community. When the Charge Nurse became aware
that Resident # 3 was unaccounted for, it was significant that she based
her subsequent actions on intuition rather than acting in a logical pre-arranged
manner based upon the evidence at hand. I find that the failure of the
Charge Nurse to consider the Missing Resident policy at 9:30 p.m. contributed
to a lack of adequate supervision by Petitioner.
Resident # 3 did not use strict sign-out procedures in accordance with long-standing practice because he had the freedom to go outside at-will to smoke on the facility grounds. However, Resident # 3 testified that when family or friends picked him up to leave the premises, they would sign him out. Tr. 201-202; HCFA Ex. 2 at 110. Resident # 3's adherence to strict sign-out rules when he left with friends in the recent past had improved prior to the accident. Tr. 216. Regardless of the Charge Nurse's intuition or strong belief that Resident # 3 was probably with friends or family who had failed to sign him out, and even if there had been times when Resident # 3 was not properly signed out, the Charge Nurse should have acted in quick response to Resident # 3 being missing, even if it turned out be a false alarm. The fact that Resident # 3 was missing, in combination with the fact that Resident # 3 was not signed out, should have set the Missing Resident policy in play. The sign-out sheet was not checked by the Charge Nurse until 12:30 a.m. on October 5, 1997. HCFA Ex. 2 at 8, 21. I find that the failure of the Charge Nurse to check the sign out sheet until 12:30 a.m. on October 5, 1997, contributed to a lack of adequate supervision by Petitioner. The Charge Nurse failed to contact
the administrator, at all. She called the local police at 4:45 a.m. The
DON was called at 5:30 a.m. Petitioner's "Missing Resident" policy required
that the first step when a resident is missing is to notify the administrator.
HCFA Ex. 2 at 131. The Charge Nurse would notify her supervisor, the DON.
This step would have been required at the earliest time that Resident
# 3 was confirmed to be missing, i.e., 9:30 p.m. on October 4, after an
initial search of the building and grounds failed to locate him. Violation
of an internal policy does not necessarily constitute a failure to meet
the requirements of a regulation, because the policy may require more
than the regulation requires. Here, I find that failure to follow the
"Missing Resident" policy contributed to a lack of adequate supervision
by Petitioner.
Petitioner cannot demonstrate that all reasonable steps to locate Resident # 3 had been taken in a timely manner. The delay by the Charge Nurse in implementing the procedures necessary to bring to bear ever-increasing resources, as needed, to the task of finding Resident # 3, was neglectful of the obligation Petitioner owed to Resident # 3. I find that Petitioner did not provide adequate supervision to prevent accidents between 9:30 p.m. on October 4, 1997, when Resident # 3 was confirmed to be missing, and 6:30 a.m. on October 5, 1997, when he was located and retrieved. Consequently, Petitioner was not in substantial compliance with 42 C.F.R. § 483.25(h)(2).
Following the October 10, 1997 survey, HCFA cited Petitioner under Tag F-490, the administration requirement. The Statement of Deficiencies first recites the general language of the administration requirement, which states the following:
The Statement of Deficiencies then states:
HCFA Ex. 1 at 5. As indicated above, I have found Petitioner deficient
under Tag F-324. Nevertheless, under the circumstances here, I will not
automatically find Petitioner deficient in "Administration," just by virtue
of having been found deficient in ensuring adequate supervision to prevent
accidents. The regulations were carefully crafted, and it was not intended
that an "Administration" deficiency be triggered each time there is some
other failure to meet participation requirements. HCFA specifically chose not to supplement the HCFA form
2567L with any additional evidence concerning Tag F-490 at the hearing.
HCFA Ex. 1; Tr. 40. There is no specific portion of the "Administration" regulation cited in the form 2567L, and no portion seems to apply to the issues in this case, except subsection 42 C.F.R. § 483.75(m), which states:
42 C.F.R. § 483.75(m). The Charge Nurse was Petitioner's highest ranking employee
in immediate charge and with responsibility for the operation of the entire
82-bed facility in the absence of any higher ranking personnel. 42 C.F.R.
§ 483.30(a)(2). She was then, for all practical purposes, designated by
management to serve as their agent during her tour of duty on the 2nd
shift and 3rd shift. Tr. 32. In the absence of the DON and
the administrator, she became de jure "Administration." Petitioner was deficient for being unable to account for
Resident # 3's whereabouts and failing to attend properly to the task
of locating and retrieving him. Resident # 3 was outside for 11-1/2 hours
(HCFA Ex. 4), 9-1/2 of which he spent on the ground. HCFA's witness stated
that, "The system that failed was one that they didn't use their walk-away
policy. . " Tr. 233. A close reading of 42 C.F.R. § 483.75(m) shows, however,
that the failure to use the missing resident
or walk-away policy is apparently not addressed by this regulation. The
requirement to have written plans and
procedures for missing residents is required by 42 C.F.R.§ 483.75(m).
The provider must also provide training and unannounced staff drills using
the procedures. Petitioner's "Missing Resident" policy was prepared for
Petitioners's staff. The HCFA surveyor agrees that the written policy
pre-existed the incident and was adequately written. Tr. 32. Petitioner's
staff recalled that a copy of the "Walk Away Resident" or "Missing Resident"
procedure was normally posted in or near the nurse's station. HCFA Ex.
2 at 5, 11, 13, 14, and 20. There is evidence that the Charge Nurse knew
of the procedure and agreed in a conversation with the surveyor that she
had received in-service training
regarding the "Walk Away Resident" or "Missing Resident" procedure. HCFA
Ex. 2 at 30 item (14). There is no evidence that Petitioner failed to
carry out satisfactorily "unannounced staff drills," as required under
this subsection. HCFA's allegation of deficiency under Tag F-490 deals
with the "implementation," not the preparation, of the emergency plans
and procedures regarding missing residents. To further my evaluation of
the "Administration" requirements, which apparently do not include implementation,
I compare 42 C.F.R. § 483.75(m), which is applicable here, with similar
provisions elsewhere in the Code of Federal Regulations. Similar paragraphs dealing with emergency plans for missing persons (clients), found in the Conditions of Participation portion of the regulations for Immediate Care facilities (ICF), state the following:
42 C.F.R. § 483.470(h). Again, the ICF regulation subsection requires the facility
to develop and implement the plans and
procedures for missing clients. Also of interest is the "Administration" section of the regulations containing standards for Veteran's hospitals (VA), which reads as follows:
38 C.F.R. § 51.210(q). The operative difference in the requirements for the three
types of health facilities relating to missing "residents" or "clients,"
is whether the word "implement" is included. For (SNF) and (VA), the word
"implement" is absent from the respective regulation subsection. But for
(ICF), regarding missing "clients," the word "implement" is included in
the regulation subsection. In the instant case, the relevant regulation
subsection, 42 C.F.R. § 483.75(m), leaves out the word "implement." The
legal implication is that if "implementation" of the "Missing Resident"
policy is required, it is covered elsewhere in the regulations. I find that HCFA has failed to establish a prima facie
case that Petitioner was not in substantial compliance with the "Administration"
requirements under 42 C.F.R. § 483.75.
HCFA determined that "immediate jeopardy" resulted from
Petitioner's noncompliance. "Immediate jeopardy means a situation
in which the provider's noncompliance with one or more requirements of
participation has caused, or is likely to cause, serious injury, harm,
impairment, or death to a resident." 42 C.F.R. § 488.301 (italics in original). Resident # 3 did not suffer serious injury, harm, impairment,
or death, so the issue is whether it was likely
that Resident # 3 would suffer serious injury, harm, impairment, or death,
as a result of Petitioner's failure to ensure that Resident # 3 received
adequate supervision to prevent accidents, as required under 42 C.F.R.
§ 483.25(h)(2). Petitioner argues that the severity level did not rise
to the level of immediate jeopardy. Petitioner argues that severity level
two (no actual harm with a potential for more than minimal harm, but not
immediate jeopardy) fits the evidence in this case. The State Operations
Manual (SOM), at Appendix P, gives guidance to surveyors that expands
upon severity level two as follows:
P. Br. at 12; See also 42 C.F.R. § 488.404(b)(ii). Petitioner points to Appendix Q of the SOM:
P. Br. at 12-13. Petitioner offered as proof that it was not likely, and there was not a high probability, that Resident # 3 would suffer serious injury, harm, impairment, or death, the following:
I agree with Petitioner. I find that it was not
likely, and that there was not a high
probability, that Resident # 3 would suffer serious
injury, harm, impairment, or death, as a result of being outside the facility,
even overnight, while Petitioner could not account for his whereabouts
and failed to attend properly to the task of locating and retrieving him.
In my view, Petitioner's only deficiency in ensuring that Resident # 3
received adequate supervision to prevent accidents, as required under
42 C.F.R. § 483.25(h)(2), is Petitioner's inability to account for Resident
# 3's whereabouts, together with Petitioner's failure to attend properly
to the task of locating and retrieving him. I make that determination, both in the abstract, based on Resident # 3's whereabouts being totally unknown, and also in concrete terms, based on where he actually was. Resident # 3 was not only cognitively intact, he was very resourceful and calm, exercised good judgment, and was effective in problem solving. If Petitioner were required merely to prove by a mere preponderance of the evidence that Resident # 3 was unlikely, by spending the night outside the facility, to suffer
serious injury, harm, impairment, or death, I would find that no immediate
jeopardy existed. The parties stipulated that Resident # 3 was exposed
to a night-time low temperature of 57 degrees. HCFA Ex. 4 (item m). Resident
# 3 characterized his experience as a "camping trip." Tr. 194. On the issue of immediate jeopardy, however, I do not
substitute my own conclusion for that of HCFA. I am constrained by 42
C.F.R. § 498.60(c)(2), which provides that the administrative law judge
upholds "HCFA's determination as to the level of the noncompliance of"
a skilled nursing facility "unless it is clearly erroneous." See
also 42 C.F.R. § 498.3(d)(10). Here, the
determination of whether there was immediate jeopardy requires some prognosticating,
some predicting of probabilities. Reasonable minds certainly can and do
differ on issues such as these. Even if the deficiency is limited to Petitioner's
inability to account for Resident # 3's whereabouts and Petitioner's failure
to attend properly to the task of locating and retrieving him, HCFA could
reasonably find that there was immediate jeopardy. Here, where HCFA's
determination differs from mine, HCFA's determination is presumed to be
correct. I find that HCFA's determination that there was immediate jeopardy
is not clearly erroneous, and, indeed, is reasonable.
Petitioner asks me to find that the alleged noncompliance
was confined to one day, because the entire episode occurred in fewer
than 24 hours. The regulations relating to per day CMPs, at C.F.R. § 488.408
(d) and (e), do not define "per day." HCFA's determination that the jeopardy
lasted two days, because the period of noncompliance occurred over two
calendar dates, is a reasonable interpretation. I agree with HCFA's determination
that the period of noncompliance lasted two days. Where there is a finding of immediate jeopardy, the minimum
daily rate for a CMP is $3,050. The $3,050 per day imposed by HCFA for
each of the two days is already the minimum, so there is no issue to address
concerning the reasonableness of the daily CMP rate.
IV. Conclusion Petitioner was not in substantial compliance with Medicare participation requirements from 9:30 p.m. October 4, 1997 through 6:30 a.m. October 5, 1997. HCFA therefore had the authority to impose a CMP. HCFA's determination that there was immediate jeopardy was not clearly erroneous. Consequently, a $6,100 CMP is reasonable. |
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JUDGE | |
Jill S. Clifton Administrative Law Judge
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FOOTNOTES | |
1. HCFA contracts with state health agencies to conduct surveys of nursing homes' compliance with Medicare participation requirements. Sections 1864 and 1819(a) of the Social Security Act (Act); 42 U.S.C. § 1395aa; 42 U.S.C. §1395i-3(g); and 42 C.F.R. § 488.20. 2. The "Missing Resident" policy and "walk away resident procedure" describe the policy found in the document in HCFA Ex. 2 at 131. | |