After a Pensacola Cluster patient was reported to have been raped last February, AHCA, the state agency that regulates intermediate care facilities, made an unannounced inspection of the facility on Feb. 22, 2018.
The investigator found that the Florida Mentor, the owner of Pensacola Cluster, had failed to take action to prevent the lack of oversight for its patients’ protection. The lack of oversight resulted in a determination of “ongoing immediate jeopardy, which has the potential to impact all 23 facility residents including sampled client #1.†(Client #1 we assume is the rape victim.)
According to the report, Pensacola Cluster failed to implement policies and procedures of REDACTED prevention policies (I assumed the redacted word is either rape or sexual assault), failed to report the assault and injuries to officials and failed to present evidence that all alleged violations were thoroughly investigated.
The facility also failed to provide nursing or medical services in accordance with client needs for five of the six residents sampled.
Pensacola Cluster failed to act upon reported, observed and documented injuries to Client #1, after Westgate called about the bruising around her hips (twice). It didn’t investigate the injuries, according to the report, and never called the Florida Abuse Hotline to report the issue.
An LPN at Westgate called the director of nursing at the facility to report that when the staff rolled Client #1 on her left side to change her, she was crying and staff could tell she was in pain. The Westgate staff called the hotline. A DCF protective services investigator visited Client #1 at the facility and ordered an x-ray, which found her left hip was broken. A routine pre-surgery pregnancy test at the hospital found she was pregnant. Law enforcement was called at that time.
The AHCA investigator reviewed the nursing notes at Pensacola Cluster and discovered Client #1 had injuries which included scratches and petechiae (Tiny, circular, non-raised patches that appear on the skin or in a mucous or serous membrane and occur as the result of bleeding under the skin.) on the left side of her face and neck and REDACTED to the left hip, REDACTED, and leg, which were not acted upon by the facility.
The Administrator said she had staff look at the injuries and determined some of the injuries may have been caused by the arm of the client’s chair rest. The staff found no problems or that she was showing signs of pain. The Administrator reported she did not believe the client was raped or that she was REDACTED. She did not call the hotline because the wheelchair may have caused the REDACTED.
She stated that the patient’s hymen could have been damaged during personal hygiene. She believed the hip was damaged because the client was dropped at the school.
The AHCA discovered the facility failed to complete body checks daily and per shift for Client #1, which is in its procedures.
AHCA returned to the facility on March 6 and the immediate jeopardy was determined to have been removed because
• The facility had done a thorough investigation dating back REDACTED for Client #1 regarding REDACTED of unknown origin.
• All 13 females had been interviewed and assessed.
• The Administrator contacted crisis intervention center for guidance on REDACTED.
• The facility implemented protocols to ensure the unusual incidents and body checks would be conducted and followed through with by management staff.
AHCA visited the facility again on March 27: “At the time of the survey all deficiencies were found to be corrected.â€
AHCA visited Pensacola Cluster on June 8 and found no deficiencies.
In reviewing the ACHA website, it doesn’t appear the facility was fined.
According to Medicaid Reimbursement Analysis, Pensacola Cluster was paid $453.23 a day to care for the victim – a little more than $165,000 annually.
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