BRADENTON -- A Bradenton extended care facility has been fined after a state agency found its staff committed a series of errors involving the death of a resident in December.
Casa Mora Rehabilitation and Extended Care, 1902 59th St. W., was assessed a $12,500 administrative fine and ordered to pay a $6,000 survey fee for the state to monitor activity at the facility, state officials said Wednesday.
In the final order issued May 10 by the Agency for Health Care Administration, Casa Mora was also placed on conditional licensure status effective Dec. 28, 2012, said agency spokeswoman Shelisha Coleman.
"Basically, a conditional status indicates that a facility did not meet, or correct upon follow-up, minimum standards at the time of an inspection," Coleman said.
The conditional status was lifted after only nine days, Coleman confirmed.
Coleman stressed Casa Mora is operating legally.
"Their license is still in good standing," she said.
Calls to Casa Mora were referred to Airamid Health Services LLC in Fort Myers. Mike Deverso, of the Airamid business development department, said the health care management consulting service is not affiliated with Casa Mora but was asked by Casa Mora to speak for them.
"This is an isolated incident by a nurse that failed to follow procedures," Deverso said. "Since then, we have worked with the AHCA and are in full compliance with state and federal regulations."
According to the AHCA investigation, a certified nurs
ing assistant at Casa Mora was making her normal rounds at 3:30 a.m. Dec. 4, 2012, and found a 58-year-old woman resident apparently not breathing with one leg hanging off the bed. The Bradenton woman had just returned from a hospital visit, suffering from cancer and depression.
When the assistant saw she wasn't breathing, four nurses responded to the call for help.
Staff "observed the resident with no vitals, not breathing and ... has expired at this time," the administrative complaint said.
No staff members initiated CPR or tried to revive the woman, even though her file indicated she was "Full Code," meaning she wished staff to try resuscitating her.
When a family member acting as the woman's health care surrogate discovered Casa Mora staff did not try to revive the woman, he filed a complaint with the AHCA, which prompted the investigation.
The AHCA report indicates confusion as to whether the woman had a standing Do Not Resuscitate order in her file. Normally, DNR patients wear a yellow wrist bracelet.
The woman was not wearing a bracelet, but one of the nurses provided a written statement saying she thought the woman was a "DNR" and "sometimes the (Casa Mora) facility staff take several days to put them (bracelets) on."
According to computer notes, staff then reported calling 911, and notified Casa Mora's risk director, the director of nursing, the woman's doctor and her family. The AHCA report did not identify staff in its report.
The woman's doctor, not employed by Casa Mora, gave them permission to remove the body, which was taken to by a funeral home.
Casa Mora did not call police until the following day, Dec. 5, according to a Bradenton Police Department report. Staff reported paramedics did not respond to their call the night of the death.
Police investigators examined the body at the funeral home Dec. 6 and found "no signs of abuse, neglect or foul play."
According to the AHCA report, administrators at Casa Mora assembled the staff involved in the incident for interviews on Dec. 4. When asked why no one performed CPR on the woman, one staffer said a Physician's Order Sheet indicated the woman was a DNR. When officials later examined the order, however, it indicated the woman was "Full Resuscitate."
Afterward, six staffers were suspended pending an investigation.
"Upon completion of their investigation, they determined that the incident was adverse, related to neglect on the facility's part," and staff retraining has begun, the AHCA reported.
Bradenton police say a nurse administrator told them two employees were terminated Dec. 5 and four others were suspended.
Deverso would not confirm if employees had been fired over the incident or update the status of those suspended.
This is not the first time Casa Mora has been fined by the AHCA. According to the AHCA website, Casa Mora was fined $500 in 2008 for filing a license renewal after a deadline. The same year, the facility was fined $500 and ordered to reimburse more than $18,000 in Medicaid overpayments.
In 2012, Casa Mora was fined another $500 for failing to submit a quarterly staffing report to the AHCA.
Calls to Dr. Azim Lalani, a family physician in Bradenton listed as Casa Mora's medical director, went unreturned.
Jim DeLa, East Manatee editor, can be reached at 941-745-7011.