Florida nursing home deaths: Owner's other facility faced state ban on new patients

Nearly three weeks before eight elderly patients died in a Hollywood nursing home, Florida regulators lifted a ban on new patients at the owner's other facility in Miami that earlier was cited for serious health and safety violations, records show.

State inspectors found 30 violations at Floridian Gardens Assisted Living Facility in December, and the next day issued a moratorium for the elder care home owned by Dr. Jack Michel, state inspection reports show. The violations included sexual assault of patients, low staffing and ignoring patients.

Florida's Agency for Health Care Administration (AHCA) deemed Michel's Floridian Gardens safe on Aug. 24, allowing the facility to accept new patients.

On Wednesday, authorities opened a criminal investigation into the deaths of the eight residents found that morning at Michel's Rehabilitation Center at Hollywood Hills. The victims were left without air conditioning after Hurricane Irma knocked out power Sunday. Dozens more patients were evacuated from the nursing home.

The state temporarily closed the nursing home and Gov. Rick Scott ordered AHCA to block Medicaid funding to the facility.

For more than a decade, state and federal authorities have cited Michel's nursing homes and assisted living facilities for health and safety violations and questionable billing practices. The state moratorium at Floridian Gardens, and more violations found later by state inspectors, are the latest examples. 

The pattern of continued violations highlights weaknesses in the system Florida uses to monitor and safeguard care for the elderly, a former ombudsmen who oversaw independent inspections of Florida's elder care facilities said Friday.

“What we all learned this week in Hollywood shows there’s a catastrophic breakdown in the system,” said Brian Lee, who served as the state's ombudsman from 2004 to 2011.  

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Michel did not respond to requests for comment Friday sent by email and phone message, and through a public relations firm offering information on behalf of his nursing home. 

A statement issued Friday on behalf of the Rehabilitation Center said the staff acted properly, and blamed problems with restoring power for the air conditioning on delays by Florida Power & Light.

"Before the storm, we put our protocols into place (approved by AHCA) for disaster situations and on our own initiative, added ten spot coolers (with temperature gauges) and fans which were distributed evenly on the first and second floors," according to the statement.

After filing an emergency service ticket with the power company Sunday, FP&L representatives said they would arrive Monday morning, according to the nursing home statement. But power crews didn't arrive until Wednesday, hours after some of the elderly patients succumbed to the heat.

"Up to and through the evacuation, protocol was followed," the nursing home's statement read. 

FP&L responded with a statement noting that the nursing home was identified as a priority, but critical facilities like hospitals and 911 centers received a higher priority.

"What we know now is that a portion of the facility did, in fact, have power, that there was a hospital with power across the parking lot from this facility and that the nursing home was required to have a permanently installed, operational generator," according to the power company statement.

Officials at the nursing home tried to reach Gov. Rick Scott three times after they lost power, but he did not respond, CBS Miami reported Friday.

Scott issued a response saying those calls were referred to state agency officials “and quickly returned.”

Scott’s office also said AHCA told the nursing home to call 911. The nursing home staff submitted 17 entries into a web-based database maintained by the state Division of Emergency Management from Sept. 7 to Wednesday, and none indicated any assistance or evacuation was required, according to Scott's office.

Michel's 180-bed Floridian Gardens facility, about 40 miles north of his nursing home where the deaths occured, was well known to AHCA inspectors. They recorded a long history of violations over the past several years, inspection reports show. 

But the most serious findings came during a Dec. 1 visit, when inspectors identified 30 health and safety violations at Floridian Gardens and immediately issued the moratorium, noting in the order that the assisted living facility:

• Failed to report or prevent a male patient's continued sexual abuse of female residents.
• Had more than 5 percent of its residents suffer recent falls.
• Left a patient in bed for three days without moving him to prevent bed sores.
• Was understaffed, at one point leaving 80 residents with only two caregivers.
• Failed to correct violations noted in previous inspections.

"Individually and collectively, these facts reflect that the residents of this facility are not currently residing in a safe and decent living environment free from abuse and neglect ..., " the report stated. "No resident of an assisted living facility should be placed or maintained in such an environment."

During the December visit, state inspectors found a resident who stated that her husband, also a resident, had fallen multiple times.

"There are no nurses here at night," the report quoted her as saying. "We do not get help. There is no way to call for help, there is no phone here."

Residents complained about another resident who kissed and fondled females.

"Staff know (he) liked to touch women and they do not do anything," one resident is quoted as saying in the report. 

Despite the moratorium, and failure to correct violations, Floridian Gardens continued to admit patients, state records show. Inspectors cited Floridian Gardens twice for re-admitting three patients after they received treatment at a hospital, according to inspection reports.

Inspectors continued finding problems even after the moratorium during seven subsequent visits, records show, including insufficient monitoring of patients and patients not receiving adequate care.

However, the state and AHCA lifted the moratorium last month, stating, "Field Office staff reported to this office that the necessary corrections have been made."

The deaths at Michel's Hollywood nursing home come after Florida has weakened its oversight of elder care by allowing the ombudsman watchdog program to lose nearly a third of the volunteer staff used to visit facilities, Lee said.

The state relies on AHCA inspectors to enforce the laws governing Florida's 683 nursing homes, but protecting the rights of the roughly 70,000 elderly patients who live in those facilities falls on the state Long-Term Care Ombudsman Program and an army of volunteers who visit facilities to monitor care.

Operators of Florida nursing home where 8 died cited for poor care, dubious billing

The number of volunteers fell nearly a third from 413 in 2007 to 281 in June, according to annual reports produced by the program. Those volunteers respond to complaints by residents or their relatives, and forward findings from their visits of possible violations to AHCA.

 “It’s really disheartening to think there’s that few volunteers because residents definitely need more volunteers to be advocating for their concerns,” Lee said. “As we see by this incident in Hollywood, the residents need these volunteers more than ever.”

Mike Milliken, the state's current ombudsman, said the number of volunteers may be higher as dozens of trainees complete a current certification program lasting four months. But he could not explain the large drop in volunteers.

"I wish I knew the answer to that because I would like to go back to that,” Milliken said. “I don’t have an answer of how we’re doing things differently than what we were doing before.”

Floridian Gardens has been cited in other claims.

In July 2016, the State of Florida and AHCA suspended Floridian Gardens from the Medicaid program after administrator Odette Barch was charged in a $1 billion Medicare fraud and money laundering scheme, the single largest health care fraud case ever brought against individuals, according to Leslie R. Caldwell, then-Assistant U.S. Attorney General for the Criminal Division of the United States Department of Justice.

The suspension was lifted after Barch was terminated and replaced, according to a settlement document.

In May, Floridian Gardens settled a state lawsuit filed by the estate of Robert Nelson, a patient who died July 1, 2016, court records show. According to the complaint, Nelson was admitted to the assistant living facility even though, "he required heightened nursing care and supervision based upon his health condition." 

The suit claimed Floridian Gardens staff didn't provide the care or treatment "to prevent him from suffering the development and deterioration of bedsores, to prevent him from suffering the development and deterioration of malnutrition and dehydration, and to prevent him from suffering the development and deterioration of hypovolemic shock," a condition that develops due to severe fluid loss.

Settlement terms were not disclosed.

Reporter Alan Gomez contributed to this article. 

The Rehabilitation Center at Hollywood Hills submitted this timeline of events after a loss of the air conditioning system during Hurricane Irma. Eight nursing home residents subsequently died. 

Sunday, September 10, 2017

• The building has two FP&L transformers that provide electrical power. One powers life safety systems and the second one only powers the AC chiller.
• At 3 p.m., electrical power in the building flickered and came back without generator assistance. The electrical power to the AC chiller went down and did not come back.
• We made our first call to FP&L at 3:49 p.m. and created an emergency service ticket number.
• Before the storm, we put our protocols into place (approved by ACHA) for disaster situations and on our own initiative, added ten spot coolers (with temperature gauges)  and fans which were distributed evenly on the first and second floors.

Monday, September 11, 2017

• FP&L told administrators they were coming in the morning to fix the electrical power for the AC chiller. Then FP&L said they would arrive in the afternoon. FP&L did not show throughout the day.  Care continued to be provided to all residents according to protocol.
• At 5:36 p.m., Natasha Anderson (VP at Larkin) contacted the Florida Emergency Information Line to report the A/C transformer issue. A representative gave her an emergency number in Tallahassee to call to report.
• At 5:39 p.m., Anderson contacted the number provided, The Florida Department of Emergency Management Private Sector Hotline, and spoke to someone named Jorge. She explained the situation and asked that we be made a priority as we were a hospital and nursing home with 162 patients. Jorge said the matter would be escalated.
• At 6:57 p.m., Anderson called Jorge back to see if there any updates to her emergency call. She was told there were not, and reassured our situation had been reported and escalated.
• At 7:29 p.m., Anderson received a call from the Florida Department of Health in Tallahassee informing her it was working on our emergency.
• At 9:24 p.m., Anderson contacted the DOH emergency line again to say she had received no updates.
• At 9:57 p.m., Anderson received a call from the DOH emergency line informing her that they were working on our request but had no updates. She again expressed the urgency of getting FP&L out to reset the A/C chiller transformer.
• It’s important to note that through Monday, the building was still cool and the spot coolers were in place maintaining required temperatures.

Tuesday, September 12, 2017

• FP&L told administrators they would be coming to fix the transformer Tuesday morning. FP&L did not show up. FP&L later said they would arrive at the center Tuesday afternoon to fix the transformer. FP&L did not show up.  Care continued to be provided to all residents according to protocol.
• At 9:58 a.m., Anderson contacted the Tallahassee DOH emergency line to inquire about the status of her calls for help. She was told there were many hospitals and health care facilities with FP&L problems due to the storm. Anderson again asked to be made a priority due to the frail and elderly resident population.
• At 12:53 p.m., we reached out to Memorial Regional Hospital and asked for additional spot coolers to help keep the center’s temperature maintained. These spot coolers were received and put in place at 3:15 p.m.
• At 1:18 p.m., we reached out to the Broward coalition and the coalition offered to send a mass email to all members to see if additional coolers could be provided. The email went out at 1:21 p.m.
• At 4:41 p.m., Anderson received a call from AHCA on behalf of the EOC. AHCA was informed of all our efforts to obtain help and keep the building cool. AHCA said they would inform emergency response teams we still needed assistance.
• Throughout the day, the center’s administrator (Jorge Carballo) and engineer (James Williams) called FP&L to try to get assistance.
• Between 6 p.m. and 11 p.m., a physician’s assistant rounded on patients to check that the patients were stable in light of the current conditions. Jorge C. was constantly rounding as the administrator (as a non-medical person) during this time frame.

Wednesday, September 13, 2017

• At 1:30 a.m., the first patient (1) had tachycardia. 911 rescue was called by the Facility. The patient was stabilized and transferred to the hospital.
• At 2:30 a.m., 911 rescue was called by the Facility when a second patient (2) had respiratory distress. The patient was stabilized and transported to the hospital.
•  At 4:30 a.m., 911 rescue was called by the Facility as a third patient (3) went into cardiac arrest. Resuscitation measures were provided. Patient was pronounced dead at the center by 911 rescue.
• At 4:30 a.m., while 911 rescue still there, a fourth (4) patient had cardiac arrest. However, the patient was on “do not resuscitate orders” and was not resuscitated.  This patient died.
• At 4:45 a.m., while 911 rescue still there, a fifth patient (5) had cardiac arrest, rescue 911 resuscitated the patient but the patient later died at the hospital.
•  At 5 a.m., our Director of Nurses was informed of the incidents. She recommended moving patients from the second floor to the first floor where it was cooler. Jorge Carballo was also contacted.
• The evacuation of patients occurred in conjunction with local authorities and Memorial Regional staff, around 6:30 a.m.
• FP&L arrived at our center to fix the transformer on Wednesday morning, hours after our residents began having health emergencies.   Up to and through the evacuation, protocol was followed.

Florida Power & Light issued this statement in response:

We extend our deepest sympathies to those who lost their loved ones. Because of the current investigations associated with these tragic events involving the nursing home, we are limited in what we can say. 

What we know now is that a portion of the facility did, in fact, have power, that there was a hospital with power across the parking lot from this facility and that the nursing home was required to have a permanently installed, operational generator.

In March, we met with Broward County officials to identify top critical facilities that require priority power restoration. While this nursing home was given a level of priority, in working with county officials, other critical facilities, such as hospitals and 911 centers, were identified as higher priorities.

As we emphasized before, during and after Hurricane Irma, we urge our customers who have electricity dependent medical needs, and who don’t have power to call 911, if it is a life-threatening situation.

In addition, we urge customers in this situation to check availability of local special needs shelters.