Department of Health and Human Services
DEPARTMENTAL APPEALS BOARD

Civil Remedies Division

Del Rosa Villa,
(CCN: 55-5195),

Petitioner
v.
Centers for Medicare and Medicaid Services.
Docket Nos. C-10-45, C-10-54
Decision No. CR2435

Date: September 21, 2011

DECISION

I sustain the determination of the Centers for Medicare and Medicaid Services
(CMS) to impose remedies against Del Rosa Villa (Petitioner or facility) for
failure to comply substantially with Medicare program participation requirements.
For the reasons that follow, I uphold the per instance civil money penalty (CMP)
of $10,000.

I. Background

Petitioner, located in San Bernardino, California, is authorized to participate in
Medicare as a skilled nursing facility (SNF). The California Department of Public
Health (the state survey agency) conducted a survey of Petitioner that was
completed on July 2, 2009, and found Petitioner not in substantial compliance with
program participation requirements. CMS notified Petitioner by letter dated
August 11, 2009, that it was imposing the following enforcement remedies: a per
instance CMP of $10,000; termination of Petitioner’s provider agreement by no
later than January 2, 2010, if substantial compliance was not promptly achieved
and maintained; and withdrawal of Petitioner’s authority to conduct a Nurse Aide
Training and Competency Evaluation Program (NATCEP). CMS Exhibit (CMS
Ex.) 40, at 1-5.

On July 10, 2009, CMS conducted a Federal Comparative Monitoring Survey of
Petitioner and found Petitioner not in substantial compliance with program
participation requirements. CMS notified Petitioner by letter dated August 13,
2009, that it was imposing the following enforcement remedies: a denial of
payment for new admissions (DPNA) effective August 27, 2009; a CMP of $250
per day, effective July 10, 2009; termination of Petitioner’s provider agreement by
no later than January 2, 2010, if substantial compliance was not promptly achieved
and maintained; and withdrawal of Petitioner’s authority to conduct a NATCEP.
CMS stated that the DPNA and CMP would continue until Petitioner returned to
substantial compliance or termination was effectuated.

Petitioner requested a hearing to appeal the findings of the July 2, 2009 survey by
letter dated October 9, 2009. The request for hearing was docketed as C-10-45
and assigned to me for hearing and decision on October 22, 2009.

Petitioner requested a hearing to appeal the findings of the July 10, 2009 survey by
letter dated October 9, 2009. The request for hearing was docketed as C-10-54
and assigned to me for hearing and decision on October 22, 2009.

By letter dated November 18, 2009, CMS requested that Docket No. C-10-54 be
consolidated with Docket No. C-10-45. In the absence of objection and for good
cause shown, I issued an Order Consolidating Cases on November 19, 2009.

On November 24, 2010, Petitioner filed a Notice of Withdrawal of Hearing
Request as to 7/10/09 Federal Survey Only.

I convened a hearing in San Francisco, California on December 6-8, 2010. CMS
offered, and I admitted, CMS Exs. 1-10, 13, 36-43, 47, and 48. Transcript (Tr.) at
27, 252-53. Petitioner offered, and I admitted, Petitioner Exhibits (P. Ex.) 1, pgs.
22-26; 32-35, 46-48, 86-131. Tr. at 30, 31, 603. CMS called two witnesses,
Surveyor Wendy Myers, R.N., and Barbara Ziv, M.D. Petitioner called the
following witnesses: Gary Hoyes, Thomas Woodbury, M.D., and Randolph
Noble, M.D. The parties filed post-hearing briefs (CMS Br. and P. Br.) and post-
hearing reply briefs (CMS Reply and P. Reply).
Procedural History:

The specifically-discussed Orders below are not the only ones issued over the
course of this litigation, but they are the ones significant in illuminating the
unusual and protracted period of prehearing development in this case.

Order Denying Motion to Continue, dated June 11, 2010: This Order contains a
summary of the procedural history of the case up to that date, and reflects the

resolution of then-pending disputes concerning the date and location of the
hearing, which at that point was to be September 7, 2010 in Santa Ana, California.

Order Regarding CMS’s Request for Subpoena, dated June 14, 2010: This Order
addresses CMS’s request for a subpoena, and states that Petitioner had filed an
objection. I directed Petitioner to comply with one of two alternatives in lieu of
issuing the subpoena, but ruled that if Petitioner did not avail itself of either
alternative, I would grant CMS’s request for a subpoena.

Order Granting Petitioner’s Request for Subpoenas, dated June 14, 2010: This
Order addresses Petitioner’s request for subpoenas, states that CMS had filed an
objection, and that Petitioner had filed an unauthorized response to CMS’s
objection. I granted Petitioner’s request for subpoenas.

Order Following Prehearing Conference, dated July 29, 2010: This Order
followed a July 27, 2010 telephone prehearing conference, at which the principal
matter discussed was the effect of an ongoing criminal investigation by state
authorities into events that are part of the background of this case. After hearing
additional comment and argument from the parties (both sides having already
explained their positions prior to the conference), I found it necessary to vacate the
September 7, 2011 hearing date because of the criminal investigation. I directed
the parties to suggest new hearing dates. At the conference, I also resolved certain
evidentiary issues and granted the parties’ unopposed pending motions by which
they sought to amend their final exchanges.

Notice of Rescheduled Hearing Date, dated August 13, 2010: This Notice
announced a new hearing date of December 6, 2010, with the location to be
announced at a later date.

Notice of Location of Hearing, dated November 10, 2010: This Notice announced
the specific location of the hearing scheduled to begin on December 6, 2010.

By Direction Letter, dated November 17, 2010: This letter informed the parties
that Petitioner’s request for a postponement of the hearing, as set forth in an email
dated November 17, 2010, was denied. In the email, Petitioner stated that the

parties had “settled the federal survey portion of this appeal.” Petitioner stated
further that it would be requesting a postponement of the hearing on the state
survey currently scheduled to begin on December 6, 2010. Petitioner represented
that CMS took no position on Petitioner’s request, as long as the hearing was
rescheduled to a date in the first half of 2011.

On November 19, 2010, Petitioner sought the intervention of an appellate panel of
the Departmental Appeals Board (Board) in this case by filing its “Request for
Review of ALJ’s Denial of Petitioner’s Motion for Stay.” The Board’s appellate
panel denied Petitioner’s request in its Ruling No. 2011-2 on December 2,

2010. Petitioner’s representations are fully set out in its pleading and require no
further discussion here except to note that they raise the same arguments
concerning a state criminal investigation that had been raised earlier to

me. Similarly, the Board’s detailed analysis of Petitioner’s request, its careful
discussion of the legal and factual context of the situation, and its determination
not to intervene in the case, are all set out in its Ruling. They require no additional
discussion.

By Direction Letter, dated November 24, 2010: This letter informs the parties
that, in order to accommodate Petitioner’s counsel’s and witnesses’ travel (see
Petitioner’s email dated November 23, 2010), the hearing would begin in the
afternoon instead of the morning of December 6, 2010.

Order of December 3, 2010: This Order states that Petitioner, in a series of emails,
renewed its efforts to win a postponement of the hearing, and that CMS responded
by email. I denied Petitioner’s motion. I found that Petitioner’s arguments
offered in support of its motion failed to demonstrate good cause for vacating the
setting of the hearing, particularly in light of the Board’s December 2, 2010
Ruling No. 2011-2. I informed the parties that I would provide a more formal oral
tuling at the hearing. Tr. at 14-23.

Order of April 25, 2011: This Order followed a telephone conference held on
April 25, 2011, which addressed Petitioner’s Motion to Supplement Record, dated
April 15, 2011, and CMS’s Objection to Petitioner’s Motion to Supplement
Record, dated April 20, 2011. I noted the importance of resolving this issue
expeditiously in this case, which has been marked by repeated delays, while at the
same time ensuring that each side’s right to a full and complete discussion of all
the evidence is preserved. Accordingly, I granted Petitioner’s motion and
permitted Petitioner to submit a set of lately-discovered documents as P. Ex. 132
for admission to the record, and allowed each side to file supplemental briefs
addressing the documents’ content. Both parties filed their supplemental briefs on
May 13, 2011, and with those filings, the record closed.
II. Issues
The issues before me are:

(1) whether the facility was in substantial compliance with 42 C.F.R.
§ 483.25(h) at the time of the July 2, 2009 survey; and

(2) if the facility was not in substantial compliance, whether the penalty
imposed, a $10,000 per-instance CMP, was reasonable.

Ill. Applicable Law and Regulations

The statutory and regulatory requirements for participation by a long-term care
facility are found at sections 1819 (SNF) and 1919 (NF) of the Social Security Act
(Act) and at 42 C.F.R. Part 483.' Section 18 19(h)(2) of the Act vests the Secretary
of Health and Human Services (Secretary) with authority to impose enforcement
remedies against a SNF for failure to comply substantially with the federal
participation requirements established by sections 1819(b), (c), and (d) of the
Act.” Pursuant to 1819(h)(2)(C), the Secretary may continue Medicare payments
to a SNF not longer than six months after the date the facility is first found not in
compliance with participation requirements. Pursuant to 1819(h)(2)(D), if a SNF
does not return to compliance with participation requirements within three months,
the Secretary must deny payments for all individuals admitted to the facility after
that date — commonly referred to as the mandatory or statutory DPNA. In addition
to the authority to terminate a noncompliant SNF’s participation in Medicare, the
Act grants the Secretary authority to impose other enforcement remedies,
including a discretionary DPNA, CMPs, appointment of temporary management,
and other remedies such as a directed plan of correction. Act § 1819(h)(2)(B).

The Secretary has delegated to CMS and the states the authority to impose
remedies against a long-term care facility that is not complying substantially with
federal participation requirements. “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 (emphasis in original). A deficiency
is a violation of a participation requirement established by sections 1819(b), (c),
and (d) of the Act or the Secretary’s regulations at 42 C.F.R. Part 483, subpart B.

' All references are to the 2010 version of the Code of Federal Regulations
(C.F.R.), which was in effect at the time of the survey, unless otherwise indicated.

* Section 1919(h)(2) of the Act gives similar enforcement authority to the states to
ensure that NFs comply with their participation requirements established by
sections 1919(b), (c), and (d) of the Act.
State survey agencies on behalf of CMS may survey facilities that participate in
Medicare to determine whether the facilities are complying with federal
participation requirements. 42 C.F.R. §§ 488.10-.28, 488.300-.335. The
regulations specify the enforcement remedies that CMS may impose if a facility is
not in substantial compliance with Medicare requirements. 42 C.F.R. § 488.406.

CMS may impose a CMP for the number of days a facility is not in substantial
compliance or for each instance of noncompliance. 42 C.F.R. § 488.430(a). The
regulations specify that a CMP that is imposed against a facility on a per day basis
will fall into one of two ranges of penalties. 42 C.F.R. §§ 488.408, 488.438. The
upper range of a CMP, $3,050 per day to $10,000 per day, is reserved for
deficiencies that pose immediate jeopardy to a facility’s residents and, in some
circumstances, for repeated deficiencies. 42 C.F.R. §§ 488.438(a)(1)(i), (d)(2).
“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
(emphasis in original). The lower range of a CMP, $50 per day to $3,000 per day,
is reserved 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. 42 C.F.R. § 488.438(a)(1)(ii). A per instance
CMP may range from $1,000 to $10,000, and the range is not affected by the
presence of immediate jeopardy. 42 C.F.R. § 488.438(a)(2).

The Act and regulations make a hearing before an administrative law judge (ALJ)
available to a long-term care facility against which CMS has determined to impose
an enforcement remedy. Act §§ 1128A(c)(2), 1866(h); 42 C.F.R. §§ 488.408(g),
498.3(b)(13). The hearing before an ALJ is a de novo proceeding. The Residence
at Salem Woods, DAB No. 2052 (2006); Cal Turner Extended Care, DAB No.
2030 (2006); Beechwood Sanitarium, DAB No. 1906 (2004); Emerald Oaks, DAB
No. 1800, at 11 (2001); Anesthesiologists Affiliated, DAB CR65 (1990), aff'd, 941
F.2d 678 (8th Cir. 1991). A facility has a right to appeal a “certification of
noncompliance leading to an enforcement remedy.” 42 C.F.R. § 488.408(g)(1); 42
C.F.R. §§ 488.330(e), 498.3. However, the choice of remedies, or the factors
CMS considered when choosing remedies, is not subject to review. 42 C.F.R.

§ 488.408(g)(2). A facility may only challenge the scope and severity level of
noncompliance that CMS determined, if a successful challenge would affect the
range of the CMP that may be imposed or impact the facility’s authority to
conduct a NATCEP. 42 C.F.R. § 498.3(b)(14), (d)(10)(i). The CMS
determination as to the level of noncompliance, including the finding of immediate
jeopardy, “must be upheld unless it is clearly erroneous.” 42 C.F.R.

§ 498.60(c)(2); Woodstock Care Ctr., DAB No. 1726, at 9, 38 (2000), aff'd, 363
F.3d 583 (6th Cir. 2003). The Board has long held that the net effect of the
regulations is that a provider has no right to challenge the scope and severity level

assigned to a noncompliance finding, except in the situation where that finding
was the basis for an immediate jeopardy determination. See, e.g., Ridge Terrace,
DAB No. 1834 (2002); Koester Pavilion, DAB No. 1750 (2000). ALJ review of a
CMP is subject to 42 C.F.R. § 488.438(e).

The standard of proof, or quantum of evidence required, is a preponderance of the
evidence. CMS has the burden of coming forward with the evidence and making a
prima facie showing of a basis for imposition of an enforcement remedy.
Petitioner bears the burden of persuasion to show by a preponderance of the
evidence that it was in substantial compliance with participation requirements or
any affirmative defense. Batavia Nursing & Convalescent Ctr., DAB No. 1904
(2004), aff'd, 129 F. App’x. 181 (6th Cir. 2005); Batavia Nursing & Convalescent
Inn, DAB No. 1911 (2004); Emerald Oaks, DAB No. 1800; Cross Creek Health
Care Ctr., DAB No. 1665 (1998); see Hillman Rehab. Ctr., DAB No. 1611
(1997), aff'd, No. 98-3789, 1999 WL 34813783 (D.N.J. May 13, 1999).

IV. Findings of Fact, Conclusions of Law, and Discussion

I make two findings of fact and conclusions of law to support this decision. I set
them forth below as separate headings in bold type and then discuss each in detail.

1. Petitioner failed to comply substantially with the requirement at 42
C.F.R. § 483.25(h) (Tag F323).

CMS’s allegations of noncompliance with 42 C.F.R. § 483.25(h) concern the care
provided to Resident 1 (R1). With respect to this citation, the Statement of
Deficiencies (SOD) alleges that an unannounced visit was made to Petitioner’s
facility on June 12, 2009, at 8:40 a.m. to investigate an entity self-reported
incident (that is, an incident reported by the facility itself) regarding the suicide of
RI. The SOD alleges that, based upon interview and record review, Petitioner
failed to provide adequate supervision for R1 to prevent accidents by failing to
supervise and monitor R1 for suicide watch at all times from June 1, 2009 through
June 11, 2009. CMS Ex. 1, at 1. The SOD alleges further that Petitioner’s failure
to supervise and monitor R1 for “suicide watch at all times” resulted in R1 going
outside of the facility at 12:30 a.m. on June 11, 2009, unaccompanied by staff,
where he hanged himself with his belt on the perimeter fence. CMS Ex. 1, at 7.
According to the SOD, “[t]hese violations presented either an imminent danger
that death or serious harm would result or a substantial probability that death or
serious physical harm would result and was a direct proximate cause of the death
of’ Rl. CMS Ex. 1, at 8.
(a) Facts

R1, a 52-year-old male, had a long history of psychiatric troubles, and on or about
April 21, 2009, he attempted suicide by jumping into the path of a moving car.
CMS Ex. 8. He was injured badly, and was admitted to Arrowhead Regional
Medical Center (Arrowhead) for treatment of his injuries, which included a
fractured left leg. CMS Ex. 8. During R1’s stay at Arrowhead, on May 8, 2009,
an orthopedist requested that R1 be evaluated by a psychiatrist. The orthopedist
noted that R1 was “[mlJedically cleared for d/c [discharge]” and stated “[p]lease
evaluate to remove 5250 hold and recommend where pt can be sent.”> P. Ex. 126;
CMS Ex. 8, at 3. Later that day, R1 received a psychiatric evaluation from Dr.
Ndlela. In his consultation note, Dr. Ndlela stated:

[R1] remains depressed and unable to take care of himself. Remains
unpredictable with intermittent thoughts of suicide. He is at risk of
harming himself if he were discharged to the community. Pt is
currently not suitable or appropriate for BH [behavioral health or
mental health facility] due to the level of care he needs.

P. Ex. 126; CMS Ex. 8, at 3. Dr. Ndlela recommended that the resident be sent to
a SNF; “cont[inue] [with] current psych meds in the SNF;” and “SW [Social
worker] eval for placement.” P. Ex. 126; CMS Ex. 8, at 3.

On May 15, 2009, R1 was prescribed Clozaril, an antipsychotic medication used
for the treatment of schizophrenia. 4 Ty, 96; P. Ex, 120, at 4.

According to an Arrowhead inpatient progress note dated May 16, 2009, an “ortho
student” examined R1, found that he was “doing well/stable,” and wrote the
following plan: “continue 1:1 sitter, psych meds titration;” “continue non WB
[weight-bearing], reinforce this to pt;” “D/C [discharge] planning, placement per
CM-SNF eval monday.” P. Ex. 125, at 5. The order for “1:1 sitter” appears in
inpatient progress notes dated May 17, May 18, May 19, and May 20, 2009.

P. Ex. 125, at 1-4.

> A “5250 hold” is an extension, for up to fourteen days, of a “5150 hold,” which
is the involuntary confinement of a person when a person is deemed to be a danger
to others or himself or herself as a result of a mental disorder. The two types of
holds refer to Sections 5150 and 5250 of the California Welfare and Institutions
Code. See Tr. at 464-67 (testimony on “5150” and “5250” holds from Petitioner’s
witness, Dr. Woodbury).

* The generic name of Clozaril is Clozapine.
On May 22, 2009, Arrowhead’s staff discharged R1 to Petitioner’s facility. P. Ex.
86, at 1; CMS Ex. 3, at 1. According to Arrowhead’s discharge orders, R1 was to
continue on Clozapine, among other medications. P. Ex. 117.

The admission documents created by Petitioner’s facility state that R1’s primary
diagnoses were fracture of the left tibia and fibula, diabetes, and hypothyroidism,
and his secondary diagnoses were back pain, depressive disorder, schizophrenia,
and suicide ideation.> P. Ex. 86, at 1; CMS Ex. 3, at 1. R1’s physician, Dr.
Wilson Gomer, gave orders stating, among other things, that Resident 1 “may
have psych, podiatry, vision, dental and auditory consult.” P. Ex. 87, at 9.

R1’s medication orders on admission included Clozaril, 100 mg. by mouth at 9:00
a.m. and 200 mg. by mouth at 9:00 p.m., to address his history of self harm,
suicidal ideation, delusions, and hallucinations related to his schizophrenia. P. Ex.
108, at 1; CMS Ex. 3, at 4. The medication record also reflects orders dated May
22, 2009, to monitor R1 each shift for delusions, hallucinations, and responding to
inner stimuli, and the method for charting the frequency of these behaviors was to
“tally by hatchmarks.”® P, Ex. 87, at 6; P. Ex. 108, at 1; CMS Ex. 3, at 4.

In an initial care plan dated May 22, 2009, Petitioner’s staff addressed R1’s
diagnoses of diabetes, his broken left leg and back pain, and hypothyroidism.
P. Ex. 94, at 1-2, 5-6.

Petitioner’s staff completed a smoking assessment on May 22, 2009. P. Ex. 130;
CMS Ex. 3, at 27. According to the assessment, R1 was physically capable of
safely conducting the activity of smoking, and did not require supervision while
smoking.

On May 30, 2009, Dr. Anthony Shin, Petitioner’s staff psychiatrist (Tr. at 482-83),
evaluated R1. In his notes, Dr. Shin stated that R1 had a history of schizophrenia.
Dr. Shin found R1’s mood to be stable, and noted that he was positive for
delusions and positive for auditory and visual hallucinations. Dr. Shin scored R1
an 18/30 on a mini-mental status exam, which, according to CMS’s expert
witness, Dr. Ziv, indicates dementia. P. Ex. 89, at 2; CMS Ex. 3, at 14; Tr. at 290-
91. According to the record, this was Dr. Shin’s only examination of Resident 1.

* CMS’s expert witness, Dr. Ziv, testified that “suicidal ideation refers to
somebody’s thoughts of killing themselves.” Tr. at 285.

° Dr. Ziv testified that the order to monitor for delusions, hallucinations, and
responding to inner stimuli was “redundant” because “internal stimuli are
delusions and hallucinations.” Tr. at 290.
10

On June 1, 2009, Petitioner’s staff completed R1’s initial Minimum Data Set
(MDS) assessment. The MDS indicated that R1 had long-term memory problems,
moderately impaired cognitive skills for daily decision-making, was easily
distracted, had periods of altered perception or awareness of surroundings, had
episodes of disorganized speech, and had mental functioning that varied over the
course of the day. P. Ex. 106, at 3; CMS Ex. 3, at 41. In the area of physical
functioning, the MDS indicated that R1 needed extensive assistance with walking,
and that he needed limited assistance with locomotion off the unit. P. Ex. 106, at
4; CMS Ex. 3, at 42. R1’s primary mode of locomotion was his wheelchair, and in
addition to wheeling himself, he also used a cane/walker/crutch. P. Ex. 106, at 5;
CMS Ex. 3, at 43. The MDS noted that R1 had been receiving an antipsychotic
medication for the past seven days. P. Ex. 106, at 7; CMS Ex. 3, at 45.

As a result of the MDS assessment, LVN Teresa Yoder prepared RAP (Resident
Assessment Protocol) summaries dated June 1, 2009, that evaluated R1 further in
certain problem areas, including cognitive, communication, and psychotherapies.
P. Ex. 106, at 11-16; CMS Ex. 3, at 49-54. In the RAP summary for the cognitive
area, LVN Yoder wrote, among other things, that R1 “has short attention span,
lose [sic] interest easily, & is prone to forget. He needs much assist [with]
decision making but cont[inues] to ignore speaker and do what he wants.” P. Ex.
106, at 11; CMS Ex. 3, at 49. LVN Yoder stated further that R1 “talks to self
and/or imaginary others and his conversation can be rambling & nonsensical a
[sic] time. His mental function does tend to vary [at] times, sometimes better
and/or worse. He is [at] risk for decline... .” P. Ex. 106, at 11; CMS Ex. 3, at
49. In the RAP summary for communication, LVN Yoder noted, among other
things, that he “has some difficulty completing his thoughts . . . [h]e does not like
to participate in a conversation, does not initiate one . . . what little he does say is
nonsensical & rambling.” P. Ex. 106, at 12; CMS Ex. 3, at 50. In the RAP
summary for psychotherapies, LVN Yoder noted that R1 had diagnoses of
depression, schizophrenia, and suicidal ideation. LVN Yoder stated that the
resident has a “[history] of responding to inner stimuli by self harm, delusion,
hallucinations and suicide attempts in past. Since his admit he has not voiced or
shown [signs or symptoms] of delusions, hallucinations, or suicide ideation.”

P. Ex. 106, at 14-15; CMS Ex. 3, at 52-53. LVN Yoder stated further that “[h]e
will remain on suicide watch.” P. Ex. 106, at 15; CMS Ex. 3, at 53.

On June 1, 2009, LVN Yoder also wrote care plan interventions for R1 that
addressed different problem areas. P. Ex. 94; CMS Ex. 3, at 28-29. Among other
things, LVN Yoder wrote “[n]otify MD if his mood or behaviors interfere [with]
his functions, safety or medical needs. Suicide watch [at] all times.” P. Ex. 94, at
3, 8; CMS Ex. 3, at 28-29. LVN Yoder wrote the phrase “[s]uicide watch [at] all
times” in red ink on the care plan. CMS Ex. 3, at 28.
11

The nurses’ weekly progress note dated May 27, 2009, indicates that R1 was on
Clozaril, that he had had no episodes of responding to inner stimuli or
delusions/hallucinations that week, and that the medication was effective. The
note indicates that there was no change in his behavior. P. Ex. 96, at 3. With
respect to “‘suicide ideation,” staff did not indicate whether R1 had manifested this
behavior or whether the medication was effective, as no boxes were checked.

P. Ex. 96, at 3. The nurses’ weekly progress note dated June 3, 2009, states that
R1 was on Clozaril, he had had no episodes that week of responding to inner
stimuli, hallucinations/delusions, or suicidal ideations, and the medication was
effective. P. Ex. 96, at 1.

On June 5, 2009, Petitioner’s interdisciplinary team consisting of DON Kelly
Powell, R.N., LVN Yoder, Anita McGowan, R.D., LVN Cindy Manzano, Social
Services Director Molly Kingsley and the Activities Director (full name unknown)
held a resident care conference review for R1. P. Ex. 105; Tr. at 90-91.
According to the care conference document, they reviewed R1’s diagnoses,
physician’s orders, his MDS/assessments, and his care plan. P. Ex. 105. The
document explicitly states at the bottom of the page (“Summary of Conference
Discussion”) that the resident’s care plan and chart were reviewed. P. Ex. 105.

The nursing notes dated June 6, 2009, at 2:30 a.m., indicate that, around the start
of the shift — that is, some time around 11:00 p.m. on June 5 — the nurse saw R1
“bouncing up & down on his bed.” The nurse called R1’s physician, Dr. Gomer,
around 1:00 a.m., and Dr. Gomer called back an hour later. The nurse observed
that the resident was “still quietly bouncing in a sitting position.” Dr. Gomer gave
a new order for two mg. of Ativan by mouth, one dose.’ The nurse administered
the Ativan to R1. P. Ex. 95, at 7; P. Ex. 87, at 3; CMS Ex. 3, at 11,77. A nursing
note dated June 6, 2009, at 6 a.m., indicates that the medication was effective and
the resident was sleeping. P. Ex. 95, at 7; CMS Ex. 3, at 77. According to an
untimed nursing note, sometime during the morning of June 6, R1 was “awake
alert ... much confusion noted.” The note states that R1 sat on his bed and
bounced non stop for two hours, then got up, went out to smoke and have lunch.
After lunch, he called his sister from the nurses’ station. R1 “could not hold still,”
and he stood up and sat down in his wheelchair repeatedly. He went to the nurse’s
station, asked for his sister’s phone number repeatedly, and was given the number.
P. Ex. 95, at 6-7; CMS Ex. 3, at 77. The nurse stated that she called Dr. Gomer
because R1’s anxiety continued to increase. Dr. Gomer gave a new order for two
mg. of Ativan every eight hours as needed and told staff to send the resident to the
ER if he showed no change in behavior or if he worsened. P. Ex. 95, at 7; P. Ex.

’ Ativan is a sedative. Tr. at 577. The generic name for Ativan is Lorazepam. Tr.
at 591.
12

87, at 3; CMS Ex. 3, at 11. Around 2 p.m., R1 was given 2 mg. of Ativan “for
severe anxiety [manifested by] bouncing & repetitive.” P. Ex. 87, at 3; see CMS
Ex. 7, at 4, 6. His bouncing continued, and he was sent to St. Bernardine Medical
Center (St. Bernardine) via ambulance for evaluation. P. Ex. 95, at 6.

On the “Resident Transfer Record” that accompanied R1 to St. Bernardine,
Petitioner’s staff indicated that the “Reason for Transfer” was “Altered Mental
Status,” and described his diagnoses related to transfer as “shaking, repetitive
motion & questioning.” Under “Baseline Mental Status,” Petitioner’s staff noted
that R1 “can’t hold still.” In the box “Other Pertinent Information,” staff noted
that R1 had been given 2 mg. of Ativan at 2 p.m. CMS Ex. 7, at 6.

On St. Bernardine’s admission record, the hospital staff wrote that the “‘patient’s
description of the reason for admission” is “anxiety.” P. Ex. 115.

The St. Bernardine ER triage assessment form notes that R1’s triage status is “non
urgent” and describes his chief complaint as “Pt agitated per staff (shaking/ -
questions).” CMS Ex. 7, at 7. Under “past medical history,” the triage nurse
noted that R1 had “diabetes,” “psych,” “htn, [hypertension],” fracture of left leg,
and, under “other,” she wrote “schizo depression | thyroid suicidal ideations.”
CMS Ex. 7, at 7. There is a “Suicide Screening” section on the form, which asks
whether the patient meets “SAD PERSONS” criteria.”* If the answer is yes, then
the nurse is directed to fill out the “suicide risk tool.” The nurse checked “No.”
CMS Ex. 7, at 8. St. Bernardine did not perform a suicide assessment of Rl. A
CT head scan was ordered, and the report stated that the resident’s “brain is
unremarkable without mass lesions or acute hemorrhage.” CMS Ex. 7, at 20-21.
The ER physician stated in his report that R1 had presented with “repetitive
motion & shaking” and noted that he had schizophrenia. CMS Ex. 7, at 9. The
physician stated, “[R1] has been lying comfortably in NAD [no acute distress] all
ED stay. No tremor, no shaking.” (emphasis in original). CMS Ex. 7, at 10. He
wrote “agitation resolved,” noted R1’s condition was improved and stable,
prescribed Ativan in the evening, and discharged R1 with an instruction sheet on
anxiety and panic attacks. CMS Ex. 7, at 10; see CMS Ex. 7, at 1. Rl was
instructed to follow up with his primary physician in two days. CMS Ex. 7, at 1;
P. Ex. 114.

A nursing note dated June 7, 2009, at 6:00 a.m., states that R1 had returned to
Petitioner’s facility from St. Bernardine the previous night — that is, the evening
of June 6 — around 11:10 p.m. P. Ex. 95, at 6. According to the nursing note, in

* “SAD PERSONS” criteria is a suicide assessment screening tool. At the
hearing, Dr. Ziv testified that “SAD PERSONS” is a mnemonic, where each letter
in “SAD PERSONS?” represents a different risk factor for suicide. Tr. at 299-300.
13

the morning, the resident was up, propelling himself freely about the facility. The
note states that R1 had “0 episodes of mania m/b [manifested by] bouncing or
repetitive action” and that staff would continue to monitor. P. Ex. 95, at 6.

Later on June 7, Petitioner’s staff completed a short term care plan to address the
problem of “mania m/b [manifested by] ‘bouncing’ & repetitive action.” P. Ex.
102, at 1; CMS Ex. 3, at 33. The objective was to have R1’s bouncing behavior
decrease in ten days. The plan stated the following approaches: monitor and chart
R1’s behavior for 72 hours, medicate as ordered, encourage him to participate in
activities, redirect his focus, and notify his physician of any change in condition or
adverse reactions. P. Ex. 102, at 1; CMS Ex. 3, at 33.

Another nursing note written on June 7, 2009, around 11:00 a.m., states that R1
was able to make his needs known, was confused, and tolerated his medications.
The note indicates there was a decrease in R1’s anxiety and repetitive motions.

P. Ex. 95, at 5; CMS Ex. 3, at 78. According to a nursing note written that night
around 11:20 p.m., no increased bouncing was noted on the shift, and the resident
was sleeping most of the time. P. Ex. 95, at 5; CMS Ex. 3, at 78. On June 8,
2009, around 3:10 a.m., a nurse wrote that there were “0 episodes of Bx
[bouncing] this shift.” P. Ex. 95 at 5; CMS Ex. 3, at 78. A nursing note later that
morning, around 11:00 a.m., states, among other things, that the resident was
confused and that a decrease in anxiety was noted. P. Ex. 95, at 5; CMS Ex. 3, at
78.

The Medication Administration Record (MAR) reveals that, on June 7, 2009, R1
exhibited delusions and hallucinations during the 7 a.m. to 3 p.m. shift. The
resident also exhibited “responding to inner stimuli” during the 11 p.m. to 7 a.m.
and 7 a.m. to 3 p.m. shifts. P. Ex. 108, at 1; Tr. at 97. The MAR shows that R1
also exhibited delusions, hallucinations, and “responding to inner stimuli” on June
8-10, 2009. P. Ex. 108, at 1; Tr. at 97.

According to the nursing notes, on June 9, 2009, R1’s sister called the facility and
reported to one of the nurses that her brother had called her and told her that he
“had homosexual microchips planted in his head, please come save me.” P. Ex.
95, at 2. The nurse checked on the resident, and stated in the nursing note that he
was “resting comfortably in bed, has not stated any of this to staff when asked
about it. He states I’m ok.” P. Ex. 95, at 2. The nurse did not report the incident
to R1’s physician or psychiatrist.

On June 10, 2009, Petitioner’s Behavioral Management Team met to discuss
Resident 1. On their report, they noted that R1 was on Ativan and Clozaril.
Under “Behavioral Problems,” the team stated “recent trip to acute [hospital]
[secondary to] bizarre behavior, fidgeting.” P. Ex. 90. The team planned to have
14

R1’s physician assess him, and noted that he had “0 expressions of suicidal
ideation at this time.” P. Ex. 90.

That same day, DON Powell spoke to R1’s sister and also to Dr. Shin. P. Ex. 95,
at 2. Dr. Shin gave a new medication order to increase the morning dosage of
Clozaril to 150 mg. P. Ex. 87, at 2; CMS Ex. 3, at 12. DON Powell also noted
that the resident requested to have regular meals for two days, and his diet was
changed from a vegetarian diet to a regular diet. P. Ex. 95, at 2; P. Ex. 87, at 2;
CMS Ex. 3, at 12.

R1’s drug record shows that around 8:00 p.m. on June 10, R1 was given 2 mg. of
Ativan because he exhibited severe anxiety. P. Ex. 108, at 6. The nursing notes
indicate that around 11:20 p.m., R1 was bouncing again and bounced himself out
of his wheelchair and crashed to the floor. P. Ex. 95, at 1; P. Ex. 98, at 2; CMS
Ex. 3, at 79. He was found between the beds next to his overturned wheelchair.
He was not injured. Petitioner’s staff called Dr. Gomer around 11:35 p.m.
According to the nursing notes, R1 was up and down several times, and he
wheeled himself to the nurses’ station and asked a nurse for a “light” for his
cigarette. P. Ex. 95, at 1; CMS Ex. 3, at 79. The nurse told him she did not have a
lighter and that he should be sleeping, not smoking. R1 went back to bed. In an
interview with Surveyor Myers, the nurse said that R1 did not usually ask for
cigarettes; he usually slept. CMS Ex. 42, at 20. The nurse called Dr. Gomer again
around 12:15 a.m, just a few minutes past midnight.

Quite soon after the call to Dr. Gomer, at around 12:30 a.m. in the very early
morning of June 11, R1 wheeled himself out the laundry room door, apparently to
smoke. He was unaccompanied by staff but was seen by at least two nurses on
his way out. CMS Ex. 42, at 20, 23. According to Surveyor Myers, one of the
nurses, Dawnetta Jones, CNA, told her that R1 said “hello” to her, and she found
this unusual because he never spoke to her and she had seen him go outside at
night to smoke only once before. Ms. Jones said that R1 always stayed in bed at
night. CMS Ex. 42, at 23.

Around 12:50 a.m., R1 was found hanging by his own belt on the perimeter fence
of the parking lot. P. Ex. 95, at 1; P. Ex. 98, at 1; CMS Ex. 3, at 79. Staff
performed CPR and called 911. R1 died shortly thereafter at St. Bernardine.

P. Ex. 95, at 1, 3; CMS Ex. 3, at 79-80.

(b) Analysis

The general quality of care regulation, 42 C.F.R. § 483.25, requires that a facility
ensure that each resident receives the necessary care and services to attain or
maintain the resident’s highest practicable physical, mental, and psychosocial
15

well-being, in accordance with the resident’s comprehensive assessment and plan
of care that the resident’s care planning team developed in accordance with 42
C.F.R. § 483.20. The quality of care regulations impose specific obligations upon
a facility related to accident hazards and accidents.

The facility must ensure that—
(1) The resident environment remains as free of
accident hazards as is possible; and
(2) Each resident receives adequate supervision
and assistance devices to prevent accidents.

42 C.F.R. § 483.25(h). The SOM, as amended in August 2007, instructs surveyors
that the intent of 42 C.F.R. § 483.25(h)(1) and (2) is “to ensure the facility
provides an environment that is free from accident hazards over which the facility
has control and provides supervision and assistive devices to each resident to
prevent avoidable accidents.” The facility is expected to: identify, evaluate, and
analyze hazards and risks; implement interventions to reduce hazards and risks;
and monitor the effectiveness of interventions and modify them when necessary.
SOM, app. PP, Guidance to Surveyors for Long Term Care Facilities, F323,
Quality of Care (Rev. 27; eff. Aug. 17, 2007).

The Board has provided interpretative guidance for adjudicating alleged violations
of 42 C.F.R. § 483.25(h)(1):

The standard in section 483.25(h)(1) itself - that a
facility “ensure that the environment is as free of
accident hazards as possible” in order to meet the
quality of care goal in section 483.25 -- places a
continuum of affirmative duties on a facility. A facility
must determine whether any condition exists in the
environment that could endanger a resident’s safety. If
so, the facility must remove that condition if possible,
and, when not possible, it must take action to protect
residents from the danger posed by that condition.
[Footnote omitted.] If a facility has identified and
planned for a hazard and then failed to follow its
own plan, that may be sufficient to show a lack of
compliance with [the] regulatory requirement. In
other cases, an ALJ may need to consider the actions
the facility took to identify, remove, or protect
residents from the hazard. Where a facility alleges (or
shows) that it did not know that a hazard existed, the
facility cannot prevail if it could have reasonably
16

foreseen that an endangering condition existed either
generally or for a particular resident or residents.

Maine Veterans’ Home — Scarborough, DAB No. 1975, at 6-7 (2005) (emphasis
added).

The Board has also explained the requirements of 42 C.F.R. § 483.25(h)(2) in
numerous decisions. Golden Living Ctr. — Riverchase, DAB No. 2314, at 7-8
(2010); Eastwood Convalescent Ctr., DAB No. 2088 (2007); Liberty Commons
Nursing and Rehab - Alamance, DAB No. 2070 (2007); Century Care of Crystal
Coast, DAB No. 2076 (2007), aff'd, 281 F. App’x 180 (4th Cir. 2008); Golden
Age Skilled Nursing & Rehab. Ctr., DAB No. 2026 (2006); Estes Nursing Facility
Civic Ctr., DAB No. 2000 (2005); Northeastern Ohio Alzheimer’s Research Ctr.,
DAB No. 1935 (2004); Woodstock Care Ctr., DAB No. 1726 (2000), aff'd, 363
F.3d 583 (6th Cir. 2003). Section 483.25(h)(2) does not make a facility strictly
liable for accidents that occur; however, it does require that a facility take all
reasonable steps to ensure that a resident receives supervision and assistance
devices that meet his or her assessed needs and mitigate foreseeable risks of harm
from accidents. Woodstock Care Ctr. v. Thompson, 363 F.3d at 589 ([A] SNF
must take “‘all reasonable precautions against residents’ accidents.”). A facility is
permitted the flexibility to choose the methods of supervision it uses to prevent
accidents, but the chosen methods must be adequate under the circumstances.
Whether supervision is “adequate” depends in part upon the resident’s ability to
protect himself or herself from harm. Jd. Based on the regulation and the cases in
this area, CMS meets its burden to show a prima facie case if the evidence
demonstrates that the facility failed to provide adequate supervision and assistance
devices to prevent accidents, given what was reasonably foreseeable. Alden Town
Manor Rehab. & HCC, DAB No. 2054, at 5-6, 7-12 (2006). An “accident” is an
unexpected, unintended event that can cause a resident bodily injury, excluding
adverse outcomes associated as a direct consequence of treatment or care (e.g.,
drug side effects or reactions). SOM, app. PP, Tag F323; Woodstock Care Ctr.,
DAB No. 1726, at 4.

There is no dispute that R1 was “seriously mentally ill, both before his admission
to Petitioner’s facility . . . and during his stay.” P. Reply at 11. As stated above,
R1 suffered from schizophrenia, a psychiatric disorder characterized by delusions
and hallucinations. CMS Br. at 1; P. Br. at 11; Tr. 267. As stated above, on April
21, 2009, less than five weeks before his admission to Petitioner’s facility, R1
attempted suicide by throwing himself in front of a moving car. A psychiatric
evaluation on May 8, 2009, stated that R1 “‘remain[ed] depressed and unable to
take care of himself... unpredictable with intermittent thoughts of suicide .. . at
risk of harming himself if he were discharged to the community.” P. Ex. 126;
CMS Ex. 8, at 3. During his hospitalization at Arrowhead, R1 had an order for a
17

“1:1 sitter,” which began at least as early as May 16, 2009, and continued at least
through May 20, 2009. When R1 was admitted to Petitioner’s facility on May 22,
2009, Petitioner’s nurse had a suicide watch in place for Rl. Beginning June 5,
2009, R1’s psychiatric condition worsened and he became increasingly disturbed,
exhibiting physical and emotional agitation, as well as auditory and visual
delusions. Six days later, after wheeling himself out of the facility in the middle
of the night, unaccompanied by staff, R1 hanged himself.

It is Petitioner’s position that CMS has engaged in “retrospective second-
guessing,” essentially “work[ing] backward from the occurrence of a tragic event
to assign blame to Petitioner.” P. Reply at 11, 25, 29. Petitioner contends that its
staff adequately supervised R1, and that his suicide, while tragic, was not
reasonably foreseeable or avoidable. Petitioner argues that its staff responded
appropriately to R1’s behavioral changes at all times and consulted with his
physician. Moreover, Petitioner maintains that its staff was alert for any “red
flags” for suicide, and asserts that none of R1’s behaviors or statements during the
days preceding his death indicated that he was at increased risk of suicide. (P. Br.
at 37-38).

Petitioner also repeatedly contends that, had any physician or psychiatrist
determined that R1 was worsening and required greater supervision, R1 would
have been transferred out of its facility to a psychiatric facility. CMS
characterizes this argument as circular reasoning, and I agree with that
characterization. Petitioner is essentially arguing that because R1 was not
transferred to another facility, R1’s condition did not warrant a higher level of
supervision. However, as CMS points out, Petitioner’s argument assumes that it
was adequately supervising Rl. CMS Reply at 9. As I discuss below, the
evidence does not support Petitioner’s claims. Despite the fact that R1 exhibited
increasing and more frequent signs of severe destabilization, Petitioner’s staff
failed to take appropriate measures to supervise him adequately and protect him
from foreseeable risks, in violation of 42 C.F.R. § 483.25(h).

At the outset, CMS points to R1’s suicide attempt and his schizophrenia as risk
factors for suicide that cannot be ignored. Citing the American Psychiatric
Association Practice Guidelines: Practice Guideline for the Assessment and
Treatment of Patients With Suicidal Behaviors (Published in November 2003)
(APA Guidelines), as well as Dr. Ziv’s testimony, CMS asserts that “a history of
past suicide attempts is one of the most significant risk factors for suicide.” CMS
Ex. 38, at 104; Tr. at 265-66. CMS notes, additionally, that suicide rates are ten
times higher in schizophrenics than in the general population. Tr. at 266-67.
CMS notes that the APA Guidelines specifically state that “suicidal ideation and
suicide attempts are common among individuals with schizophrenia and need to
be identified and addressed in the assessment process.” CMS Ex. 38, at 113.

18

In arguing that R1 required close supervision in light of his psychiatric history,
CMS references both the “1:1 sitter” order in place while R1 was hospitalized at
Arrowhead, and the “suicide watch” intervention written by LVN Yoder on his
care plan when he was admitted to Petitioner’s’ facility. With respect to the “1:1
sitter” order, CMS alleges that Petitioner’s staff failed to include this as a care plan
intervention. ’ CMS contends that R1 continued to require a “1:1 sitter” after
leaving Arrowhead as a precaution against another suicide attempt, and the
omission of this crucial intervention demonstrates a failure by Petitioner to
appropriately address his risk of suicide.

CMS alleges further that Petitioner failed to implement and communicate to staff
the suicide watch intervention contained in R1’s care plan. I have noted above
that LVN Yoder wrote the words “suicide watch at all times” in red on R1’s care
plan. P. Ex. 94, at 3, 8; CMS Ex. 3, at 28-29. In her interview with Surveyor
Myers, LVN Yoder stated that she wrote the suicide watch intervention because
she had reviewed R1’s records from Arrowhead and believed that R1’s history of
psychiatric issues and a recent suicide attempt warranted heightened monitoring.
Tr. 77-78. As testified by Surveyor Myers, no one on Petitioner’s staff who
provided direct care to R1, with the exception of LVN Yoder, was aware that R1
had an intervention for a suicide watch or that he needed more supervision related
to his prior suicide attempt. Tr. at 85; CMS Ex. 42, at 17-18, 21, 24; CMS Br. at
12. Surveyor Myers noted that not even the two staff persons who observed R1
leaving the facility on the night he committed suicide knew that he was on a
suicide watch. CMS Ex. 42, at 21, 24.

In addressing the “1:1 sitter” order, Petitioner claims that CMS’s interpretation of
it is not reasonable. According to Petitioner, Arrowhead’s “1:1 sitter” order was
an order for one-on-one supervision of R1 to prevent him from ambulating on his
broken leg, and was not meant as one-on-one monitoring because of risk for
suicide. P. Br. at 18, 45. Petitioner asserts that the fact that Arrowhead’s hospital
progress notes (dated May 16, May 18, and May 20, 2009) were written by
someone in the orthopedics department (the “ortho student” could have been an
intern, a resident, or simply a student) shows that the “1:1 sitter” order was
unrelated to R1’s psychiatric condition. Moreover, Petitioner, citing Dr. Noble’s
testimony, contends that an orthopedic student is not qualified to order psychiatric
interventions. P. Br. at 18; Tr. at 563-64.

° Dr. Ziv testified that “[a]n order for one-to-one sitter means that there is one
person assigned to one patient. That means that if I’m a sitter and I’m assigned to
you, that my responsibility is to keep you safe and nobody else.” Tr. at 277-78.
19

I cannot find Petitioner’s characterization of Arrowhead’s “1:1 sitter” order even
marginally plausible. I cannot imagine how Arrowhead could have intended to
limit the “sitter” order to the simple monitoring of R1 so that he stayed off his
broken leg. At the hearing, when asked why a patient would be put on a one-to-
one sitter, CMS’s expert witness, Dr. Ziv, explained, “Because they are not
reliable to keep themselves safe, with a less restrictive setting, meaning with just
nursing observation or observation in a milieu.” Tr. at 278. Arrowhead’s staff
knew that R1 had attempted suicide by throwing himself in front of a car and that
he remained suicidal. According to the psychiatric consultation, R1 remained
depressed and unpredictable with intermittent thoughts of suicide. It is clear that
the requirement for a “1:1 sitter” was in response to R1’s serious psychiatric
issues, and was intended as a measure to keep him safe by minimizing any future
suicide risk. To suggest that the “1:1 sitter” order was merely taking “precautions
against weight bearing,” as Petitioner claims, is, to be blunt, an absurdity."

Petitioner also challenges CMS’s understanding of the “suicide watch”
intervention in R1’s care plan, and attempts to downplay its meaning and
significance. Petitioner contends that “the notation did not — and could not —
mean the same in a nursing facility as it does in an acute psychiatric facility.”

P. Reply at 6 (emphasis in original). Petitioner asserts that the term “suicide
watch” is used only in connection with a patient who is actively suicidal, and, in
R1’s case, there was “no indication in the record that any sort of intensive
monitoring, whether called ‘suicide watch,’ ‘one-to-one,’ or anything else, ever
actually was necessary based on [R1’s] demeanor and behavior during his stay at
Petitioner’s facility.” P. Posthearing Brief at 26. Moreover, citing the testimony
of its witness Dr. Woodbury, Petitioner contends that only a physician can order a
“suicide watch,” and there was no such physician’s order for this intervention. Tr.
493-94. Petitioner faults LVN Yoder for writing the “suicide watch” intervention,
stating that she used “inartful” language and was “overzealous” since R1 had not
shown any signs of being suicidal.'' P. Br. at 25. According to Petitioner, LVN
Yoder’s intention in writing the intervention was not for staff to provide one-to-
one supervision of R1 at all times, but for staff to be alert to any signs of suicidal
ideation. (P. Brief at 46; P. Reply at 24.) To the extent that staff were to be
responsive to such signs, Petitioner contends that this was carried out. As further
support for its effort to mark the suicide watch intervention as inappropriate,
Petitioner noted that CMS’s expert witness Dr. Ziv herself testified that she could

' Moreover, CMS notes that an Arrowhead social worker told Surveyor Myers
that R1 was placed on this order because of his psychiatric issues. CMS Reply at
12.

'' LVN Yoder was “counseled” by her supervisors at the facility — at some time
after R1’s suicide, of course — for writing the suicide watch intervention.
20

not recall having seen a patient on a “suicide watch” outside of a psychiatric
facility. Tr. at 292-93. I shall discuss this point more particularly below.

Contrary to what Petitioner argues, I find that any “problem” with LVN Yoder
having made the “‘suicide watch” notation in R1’s care plan is an administratively-
or heirarchically-derived “problem,” not one of substance. After reviewing R1’s
records from Arrowhead, LVN Yoder identified R1 to be at risk for suicide, and
wrote an intervention that addressed that risk. Regardless of whether her choice of
words was “‘inartful” or precise and fitting, it is evident that LVN Yoder was
concerned about R1’s safety and wanted to make others aware that he needed
close supervision. Had she not written the suicide watch intervention, she would
have been derelict in her responsibilities to both R1 and to her professional
caregiver colleagues. Even if LVN Yoder had never made such a notation, the
circumstances of R1’s admission to Petitioner’s facility, combined with his
increasingly severe symptoms of psychosis (which I describe further below),
would have almost certainly required someone else at the facility to make a
“suicide watch” notation. If this narrative has a hero, it is LVN Yoder.

CMS notes also that, during a Resident Care Conference Review for R1 on June 5,
2009, Petitioner’s interdisciplinary team (DON Powell, LVN Yoder, SSD
Kingsley, and LVN Manzano) reviewed documents, including R1’s care plan, and
left LVN Yoder’s “suicide watch” intervention in place on the care plan, as written
in red ink. Had there been any questions about the appropriateness of the wording,
one would expect that the team would have addressed them. Since no changes
were made, I cannot avoid the obvious conclusion that Petitioner’s
interdisciplinary team intended for this intervention to remain in effect as written
in that red ink. Petitioner counters this by suggesting that “[a] more reasonable
inference” is that the interdisciplinary team was more focused on R1’s actual
condition and behavior, than on the wording of the intervention. P. Reply at 24.
According to Petitioner, because its team found that R1 was not exhibiting suicidal
ideations or behavior, there was no need to change the care plan to reflect more
intensive monitoring or to consider a transfer of R1 to a psychiatric facility. P.
Reply at 24. I do not find Petitioner’s explanation persuasive. It was incumbent
upon the interdisciplinary team to review the care plan interventions as written, in
conjunction with examining R1’s condition and behavior. If Petitioner’s team
believed the suicide watch wording was unnecessary or inappropriate, it would
have modified it, not ignored it. Because the intervention was left in place on
RI1’s care plan, the “more reasonable inference” is that it was meant to be
implemented by staff.

Although Petitioner acknowledges that R1 experienced “several changes of
condition” beginning on June 6, it asserts that “none [were] related to suicidality.”
P. Brief at 27. Instead, Petitioner takes the position that many of R1’s symptoms
21

were “typical manifestations of schizophrenia” (P. Reply at 20) and maintains that
it provided interventions and supervision appropriate for R1’s condition.
Petitioner notes that its staff consulted with Dr. Gomer regarding R1’s bouncing
behavior, that Dr. Gomer sent R1 to St. Bernardine for evaluation, and that upon
R1’s return to the facility from the hospital, its staff completed a short term care
plan on June 7, 2009, to address the “problem” of “mania [manifested by]
‘bouncing’ & repetitive action.” P. Ex. 102, at 1. Petitioner asserts further that its
staff monitored and charted R1’s behavior for 72 hours, as directed by the care
plan (P. Ex. 102, at 1), and documented that R1 “exhibited no more instances of
mania or anxiety during that time.” P. Br. at 28. In Petitioner’s view, the series of
events documented from June 6 up until the time of R1’s suicide did not raise any
red flags that R1 was suicidal or a danger to himself or others. P. Br. at 3, 43.
According to Petitioner, at no time did anyone suggest “that more intensive
supervision was necessary.” P. Br. at 43.

Contrary to Petitioner’s claim that R1’s behavioral changes did not present any
“red flags,” there can be little question that beginning June 5, 2009, R1 exhibited
signs indicating that he was severely destabilizing and headed for a crisis down a
road marked with every imaginable warning sign. Those signs included a history
of a recent and particularly-violent attempt at self-destruction, increasingly-erratic
speech and behavior, a mounting state of physical agitation, and the onset of
bizarre hallucinations. Over the course of several days, the nursing notes and
medication records show all of these indicators of increased aggravation in R1’s
disturbed state. Yet, despite R1’s behavioral changes and worsening condition,
Petitioner’s staff failed to take action and provide him with adequate supervision
to keep him safe, with predictably-tragic consequences.

Around 11:00 p.m., on June 5, 2009, a nurse observed R1 “bouncing up & down”
on his bed. R1 was “still quietly bouncing” at 2:00 a.m., when Dr. Gomer
returned the nurse’s telephone call and gave an order of two mg. of Ativan. P. Ex.
95, at 7. During the morning of June 6, 2009, R1 was described as confused and
again showed agitation. According to the nursing note, R1 sat on his bed and
again bounced nonstop for two hours, then got up, went out to smoke and have
lunch. After lunch, he called his sister from the nurses’ station. The nursing note
states that R1 “could not hold still” and he stood up and sat down in his wheelchair
repeatedly. P. Ex. 95, at 7; CMS Ex. 3, at 77. Because Resident 1’s anxiety
continued to increase, the nurse called Dr. Gomer, who gave a new order for two
mg. of Ativan every eight hours as needed and to send the resident to the ER if he
showed no change in behavior or if he worsened. P. Ex. 95, at 7; P. Ex. 87, at 3;
CMS Ex. 3, at 11. Around 2 p.m., R1 was given 2 mg. of Ativan “for severe
anxiety [manifested by] bouncing & repetitive.” P. Ex. 87, at 3; see CMS Ex. 7, at
4, 6. His bouncing continued, and he was sent to the ER at St. Bernardine to be
evaluated. P. Ex. 95, at 6.

22

In discussing the transfer of R1 to St. Bernardine, CMS argues that Petitioner
failed to inform St. Bernardine of R1’s complete psychiatric history, including his
recent suicide attempt, and as a result, St. Bernardine’s staff was unable to assess
RI adequately. Petitioner disputes this and asserts that its staff provided St.
Bernardine with background information regarding R1’s psychiatric history and
that R1 received “a very thorough workup, including a CT scan” of his brain.

P. Br. at 27. According to Petitioner, the nurse completing the admission
assessment found no reason to do a suicide screening. P. Br. at 27. Moreover,
Petitioner notes that the emergency department physician ultimately diagnosed a
panic or anxiety attack and sent R1 back to Petitioner’s facility the same day.

I find it reasonable to infer, based on the record, that Petitioner’s staff failed to
give a complete picture of R1’s mental illness to St. Bernardine’s medical
personnel when he was transferred. Notwithstanding Petitioner’s assertions, there
is no evidence that anyone from the facility informed the hospital of R1’s recent
suicide attempt. On Petitioner’s Resident Transfer Record, which accompanied
R1 to St. Bernardine, Petitioner’s staff indicated that the “Reason for Transfer”
was “Altered Mental Status,” described his diagnoses related to transfer as
“shaking, repetitive motion & questioning” and noted his baseline mental status as
“can’t hold still.” CMS Ex. 7, at 6. In the box “Other Pertinent Information,”
staff noted that R1 had been given 2 mg. of Ativan at 2 p.m. CMS Ex. 7, at 6.
Nowhere on Petitioner’s Resident Transfer Record does Petitioner’s staff mention
R1’s recent suicide attempt.

The fact that R1 did not receive a suicide screening also strongly suggests that St.
Bernardine did not receive all pertinent information about R1’s psychiatric
condition from Petitioner’s staff. CMS, citing the testimony of Dr. Ziv, points out
that, on St. Bernardine’s suicide screening tool known as “SAD PERSONS”
criteria, R1 met at least six criteria.'? Specifically, R1 had had a previous suicide
attempt, was psychotic, had no spouse or social supports, had medical illnesses,
and suffered from depression. Tr. at 299-300. Dr. Ziv testified that when a person
scores “at least six,” that score represents a level of risk that warrants a suicide
screening. Tr. at 299-300. Clearly, had St. Bernardine’s medical personnel been
informed of R1’s recent suicide attempt, they would have assessed R1 using the
SAD PERSONS criteria, which would have resulted in a suicide screening.

© According to Dr. Ziv, “SAD PERSONS” is a mnemonic device where each
letter represents a risk factor for suicide. A point is assigned for each risk factor
that a person meets. Tr. at 299.
23

It is also questionable whether the ER physician even knew about R1’s suicide
attempt. On his report, the physician wrote that R1 had presented with “repetitive
motion & shaking” and noted that he had schizophrenia. CMS Ex. 7, at 9. He
wrote “agitation resolved” (CMS Ex. 7, at 10), noted R1’s condition was improved
and stable, prescribed Ativan and discharged R1 with an instruction sheet on
anxiety and panic attacks. The ER physician makes no mention about R1’s recent
suicide attempt, which suggests that he was unaware of it.

Further, I find no substance in Petitioner’s assertion that R1’s CT head scan is
proof that St. Bernardine received R1’s complete psychiatric history from
Petitioner’s staff.'> R1’s CT scan was performed to rule out certain neurological
diagnoses and does not in any way demonstrate that St. Bernardine’s staff was told
of R1’s recent suicide attempt or had a complete picture of his mental illness. In
fact, when asked why a CT scan would have been performed on R1, both of
Petitioner’s expert witnesses, Dr. Noble and Dr. Woodbury, testified along similar
lines. Dr. Noble testified that “certain tumors or conditions inside the brain can
have an effect on behavior,” and stated that a CT scan would be a way “to make
sure that he hadn’t fallen, struck his head, for example, a blood clot on it that was
causing him to be agitated.” Tr. at 578. According to Dr. Woodbury, the purpose
of the CT scan would have been “[t]o determine if there was any anatomical
abnormality, brain tumor, stroke, for the agitation that he had had at the nursing
facility.” Tr. at 508.

The record shows that after R1 returned to Petitioner’s facility from St.
Bernardine, he continued to show signs of severe emotional and physical agitation
until his suicide. As documented in the medication record, from June 7 through
10, R1 manifested delusions, hallucinations, and “responded to inner stimuli.”

P. Ex. 108, at 1; CMS Ex. 3, at 63. On June 9, R1 called his sister and told her
that he “had homosexual microchips planted in his head, please come save me.”
P. Ex. 95, at 2. When the nurse checked on R1 after being informed of this
delusion by the sister, R1 said he was “ok.” P. Ex. 95, at 2. The nurse did not
report this incident to R1’s physician or psychiatrist.

On June 10, 2009, Petitioner’s Behavioral Management Team had a meeting to
discuss RI. P. Ex. 90. That same day, Dr. Shin gave a new medication order to

8 On R1’s CT scan report, the radiologist listed “Anxiety” under “Clinical data”

and also stated “Indication: fall,” which suggests that “anxiety” was being used to
describe R1 clinically and that there was a chance he may have fallen. CMS Ex.
7, at 20. There is nothing in the report to suggest that the radiologist had any
information about R1’s recent suicide attempt.

24

increase the morning dosage of Clozaril to 150 mg. P. Ex. 87, at 2; CMS Ex. 3, at
12.

As I have noted above, events began moving swiftly toward their conclusion at the
facility’s fence. Around 8:00 p.m. on June 10, R1’s narcotic record shows that he
exhibited severe anxiety and was given 2 mg. of Ativan. P. Ex. 108, at 6. Later,
at around 11:20 p.m., R1 was bouncing in his wheelchair and evidently became so
agitated that, in spite of the multiple healing fractures of his left leg, he bounced
himself out of his wheelchair and crashed to the floor. Despite the late hour, R1
did not go to sleep, but was up and down several times, and wheeled himself to the
nurses’ station and asked a nurse for a “light” for his cigarette. P. Ex. 95, at 1;
CMS Ex. 3, at 79. The nurse told him she did not have a lighter and that he should
be sleeping, not smoking. R1 went back to bed. Around 12:30 a.m. on the
morning of June 11, R1 wheeled himself out the laundry room door, apparently to
smoke. He was unaccompanied by staff and observed by at least two nurses on his
way out. CMS Ex. 42, at 20, 23. Shortly thereafter, R1 hanged himself from the
perimeter fence of the parking lot with a belt around his neck. P. Ex. 95, at 1;

P. Ex. 98, at 1; CMS Ex. 3, at 79.

As support for its arguments that R1’s mental state severely destabilized and that
he required close supervision , CMS offered the testimony of its expert witness,
Dr. Barbara Ziv, who is Board-certified in psychiatry and neurology. Tr. at 255-
56. Dr. Ziv testified that R1 “had multiple risk factors for suicide.” Dr. Ziv
testified:

The most robust risk factor is his recent serious suicide attempt. Other risk
factors include his sex, the fact that he has a diagnosis of schizophrenia, the
diagnosis of depression, poor social supports and . . . low socio-economic
status was also associated with suicide risk.

Tr. at 265.

Dr. Ziv emphasized that “[t]he number one risk factor for a suicide attempt is the
history of a suicide attempt” and that “anyone who has a serious suicide attempt . .
. needs to be viewed . . . with great caution, in terms of their . . . evaluating them
and following them from a psychiatric perspective.” Tr. at 266. According to Dr.
Ziv, suicide rates are higher in people with schizophrenia than in the general
population, and estimated that the percentage is 10 times higher in the
schizophrenic population. Tr. at 265, 266-67. Dr. Ziv testified that she strongly
disagreed with Petitioner’s Administrator’s characterization that R1’s suicide
attempt “was in the past” and “not pertinent to . . . his residency” at Petitioner’s
facility. Tr. at 331; see Tr. at 87.
25

Dr. Ziv testified that when R1 was evaluated by the facility’s staff psychiatrist, Dr.
Shin, on May 30, he was described as having delusions and hallucinations, which
indicated that R1 “was still actively psychotic at that time.” Tr. at 289-90.'* Dr.
Ziv noted that Dr. Shin did not address whether R1 was suicidal or homicidal in
his consultation note. Tr. at 330. Dr. Ziv also pointed out that Dr. Shin reported
that R1’s mini-mental status was 18 out of 30, which indicated dementia. Tr. at
291. When asked whether R1 was someone whom she expected would have
expressed suicidal ideations, Dr. Ziv testified that R1 was “someone you would
expect to demonstrate behaviorally, that he was getting worse and in fact, the
records support that.” Tr. at 289. According to Dr. Ziv, R1 was “not likely to be
reliable” when asked whether he had suicidal thoughts. Tr. at 291. However,
even given his unreliability, Dr. Ziv testified that she found no evidence in the

record that Petitioner’s staff ever asked him about suicidal ideations. Tr. at 291-
92.

Dr. Ziv testified that R1 exhibited behavioral changes that indicated that he was
destabilizing. According to Dr. Ziv, beginning at least on June 6, the date of R1’s
transfer to St. Bernardine’s ER for his bouncing behavior, R1 “became
increasingly unstable from a psychiatric point of view.” Tr. at 294. She testified
that R1’s decreased sleeping from June 6 until his suicide was also a sign that he
was destabilizing. Tr. at 295. Dr. Ziv testified that R1’s “bouncing” behavior was
what is known as “motor restlessness” or “psycho-motor agitation” and can be
evidence of a “psychosis,” “agitation,” “anxiety” or “pain.” Tr. at 294, 300. Dr.
Ziv expressed her opinion that the emergence of this agitation warranted a
psychiatric evaluation because it indicated that R1’s symptoms were worsening
and that he was not stable. Tr. at 300-01. Moreover, Dr. Ziv noted that, on the
short term care plan developed after R1 returned to the facility from St.
Bernardine’s ER, Petitioner’s staff described R1’s problem as “mania.” Tr. at 301.
Dr. Ziv testified that “mania” is a psychiatric diagnosis, and the use of the term on
the care plan was incorrect and made “no clinical sense” because R1 had not been
documented as exhibiting manic behavior and had not been given such a
diagnosis. Tr. at 301, 343-44.

‘4 Dr. Ziv testified that R1 was evaluated by the psychiatrist eight days after he
was admitted to Petitioner’s facility. In Dr. Ziv’s opinion, this was an “unduly
long period of time, given the fact that the patient’s admission to the medical
hospital was secondary to a suicide attempt” and that R1 “should have been
evaluated by a psychiatrist from [Petitioner], either on the day of admission or
prior to admission.” Tr. at 313.
26

In testifying about R1’s delusion of having a homosexual microchip implanted in
his brain, Dr. Ziv characterized this as “evidence of a troubling delusion,” noting
that he had cried out for his sister to save him. Tr. at 295-96. On cross-
examination, Dr. Ziv noted that Petitioner’s DON had a communication with the
psychiatrist after this incident, and the psychiatrist gave a telephone order to
increase the dosage of Clozaril. Tr. at 353. When asked why a psychiatrist would
have increased the dosage under those circumstances, Dr. Ziv response was that
R1 was “increasingly psychotic.” Tr. at 354. In Dr. Ziv’s opinion, after learning
about R1’s delusion, Petitioner’s staff had an obligation to speak with R1’s
physician and request that he examine R1 in person and not simply give an order
over the telephone. Tr. at 357.

Dr. Ziv testified further that the presence or emergence of delusions or
hallucinations were warning signs in the case of R1. Tr. at 302. Stressing the
need to be aware of R1’s “whole picture,” Dr. Ziv testified:

[R1] has a history of a serious suicide attempt. He has psychotic
symptoms. He was not -- he was independent of a one-to-one sitter,
before he came [to Petitioner’s facility], and now, you know, less --
you know, about two weeks into it, he is becoming worse, from a
psychiatric perspective. He is demonstrating a worsening of all of
his psychotic symptoms, and you referred to the American
Psychiatric Association. The treatment guidelines for hospitalization
for psychiatric illness include the presence of psychosis or an
exacerbation of psychotic symptoms in somebody who has a recent
suicide attempt.

Tr. at 302-03; see Tr. at 332. In Dr. Ziv’s opinion, R1 “demonstrated severe
psychiatric disturbances” and worsened to the point that Petitioner’s staff should
have transferred him to a psychiatric facility so he could have received adequate
treatment. Tr. at 306-07. On cross-examination, Dr. Ziv testified that she believed
that R1’s documented behaviors, including his microchip delusion, agitation, and
his history, were “serious enough” that nursing staff should have said to the
physician, medical director or the nursing home administrator, “[t]his patient
needs a face-to-face evaluation.” Tr. at 358.

With respect to the “suicide watch” wording on R1’s care plan, Dr. Ziv testified on
cross-examination that because “[s]uicide is a behavior that’s associated with
psychiatric illness,” she believed that it was “inappropriate for a nursing home to
put somebody on a suicide watch.” Tr. at 359-60. Dr. Ziv testified that if a
resident really needs a suicide watch, the resident should not be in a skilled
nursing facility. Tr. at 361. On re-direct examination, Dr. Ziv stated that a suicide
watch intervention would not be necessary for someone who had a remote history
27

of a suicide attempt and no current psychiatric symptoms. Dr. Ziv noted,

however, that she did not agree with the characterization, attributed to the DON, of
the suicide watch intervention being “unnecessary” for R1. Dr. Ziv testified that
she believed the suicide watch “was necessary and inappropriate in this nursing
home.” Tr. at 363.

To rebut CMS’s arguments, Petitioner offered the testimony of its expert witness
Dr. Randolph Noble, who is Board-certified in internal medicine, pulmonary
medicine, psychiatry, and in the past was also Board-certified in hyperbaric
medicine. Tr. at 547. Dr. Noble testified that a previous suicide attempt is one of
the major risk factors for suicide. Tr. at 596. He stated that there was “about a 10
percent risk of completed suicide with schizophrenia.” Tr. at 551, 567, 596.

Dr. Noble testified that the fact that Rl may have been exhibiting delusions,
agitation, or hallucinations did not indicate that R1 was actively suicidal. Tr. at
566-67. He testified that there is no correlation between agitation, such as R1’s
bouncing behavior, and the risk of suicide. Tr. at 554, 567. Dr. Noble opined that
the exact cause of R1’s bouncing behavior was unknown, but possible causes
could have been an anxiety manifestation in the form of a panic attack, pain,
delusion, or a drug side effect. Tr. at 554-55. When asked about the delusion R1
described to his sister in which he believed that a homosexual microchip had been
implanted in his brain, Dr. Noble testified that the delusion was “very bizarre” and
“very typical” of patients with paranoid schizophrenia. Tr. at 582; see Tr. at 549.
In Dr. Noble’s opinion, R1’s delusion was not a sign that he was decompensating
or becoming significantly worse because the type of delusion he had was “very
common, and he expressed it to a family member, and this is not a harbinger of
suicide, imminent suicidality.” Tr. at 583. According to Dr. Noble, “[t]hese
people live with those delusions” and “don’t act out, in a suicidal fashion.” Tr. at
567.

Dr. Noble expressed the opinion that, from June 7 through 10, there was no
evidence that R1 had expressed any suicidal ideations or was agitated. Tr. at 584.
According to Dr. Noble, R1’s problems did not present any red flags, and
Petitioner’s staff had no reason to implement one-to-one supervision of R1 or
enhanced monitoring of any sort. Tr. at 584-85.

As further support for its contention that R1’s psychiatric condition did not present
any red flags, Petitioner also offered the expert testimony of Dr. Thomas
Woodbury, Petitioner’s Medical Director.'” Dr. Woodbury is Board certified in

'S Dr. Woodbury testified that he is currently the medical director at eight or nine
nursing facilities. Tr. at 461.
28

family practice, hospice and palliative care, and has a “qualification in geriatrics.”
Tr. at 461.

Dr. Woodbury testified that his role as Petitioner’s Medical Director is “more of
an oversight role” and that he no longer attends to patients at Petitioner’s facility.
Tr. at 462. Dr. Woodbury testified that he had not given any orders for R1 and
that he “may have seen [R1] in years passed, but not at this time.” Tr. at 463.

Dr. Woodbury testified that he does not “personally treat schizophrenia directly”
and does not consider himself qualified to deal with someone with uncontrolled
schizophrenia. Tr. at 521. Dr. Woodbury stated that he has a psychiatrist on any
case involving a schizophrenic patient. Tr. at 521. According to Dr. Woodbury,
Dr. Shin is Petitioner’s staff psychiatrist, and in that role, Dr. Shin oversees the
behavior management team. Tr. at 481-83.

Dr. Woodbury stated that there was nothing in the record from which to infer that
R1 continued to be a danger to himself or others, after his psychiatric evaluation at
Arrowhead on May 8. Tr. at 477. Moreover, he opined that nothing in the record
shows that R1 was not appropriately supervised by Petitioner’s staff. Tr. at 516.
According to Dr. Woodbury, he saw no red flags in R1’s record that made him
concerned that R1 was exhibiting behaviors that could have been indicative of a
potential suicide attempt. Tr. at 498, 499. Dr. Woodbury testified that R1’s
mania, rapid talking, and agitation were “red flags for uncontrolled
schizophrenia.” Tr. at 499. He opined that, “[a]sking to go out to smoke, having
agitation is a very common problem in nursing facilities, in general.” Tr. at 499.

I cannot find that Dr. Woodbury’s opinions are entitled to be given any weight in
the factual context of this case. Dr. Woodbury is not a psychiatrist. He gave no
treatment orders for R1. By his own admission, he had not even seen R1 for many
years. Dr. Woodbury was simply not qualified to provide credible testimony on
RI’s psychiatric condition. While he stated that there was nothing in the record
from which to infer that R1 continued to be a danger to himself or others, and that
he saw no red flags in R1’s record that caused him to have concern that R1 was
exhibiting behaviors that could have been indicative of a potential suicide attempt,
his opinions were clearly based on speculation.

Petitioner also offered the expert testimony of Gary Hoyes, a health care services
consultant. Tr. at 373-81. The thrust of Mr. Hoyes’s testimony focused on the
distinctions in admissions and discharge criteria of skilled nursing facilities and
psychiatric facilities, the limitations of skilled nursing facilities in their ability to
care for patients with serious psychiatric problems, and the appropriateness of
R1’s admission to Petitioner’s facility.
29

I find that Mr. Hoyes’ testimony has no bearing on the issues in this case. Mr.
Hoyes has no medical background. He has never served as a permanent nursing
home administrator, and he has served as an “interim nursing home administrator”
twice, once for six months, and another time for a year. Tr. at 456-57. While he
gave mostly hypothetical opinions, Mr. Hoyes has little practical experience in the
areas about which he testified. For these reasons, I find that Mr. Hoyes’ testimony
is not entitled to be given any substantial weight. '°

In evaluating the expert testimony offered by Dr. Noble and Dr. Ziv, I find that the
opinions of Dr. Ziv are entitled to more weight when considered as a whole in
light of other evidence in the record. Dr. Ziv’s credible expert opinion is that R1
exhibited obvious signs that his mental health was deteriorating and that
Petitioner’s staff failed to take appropriate action. Her testimony indicates that
despite Petitioner’s claims that its staff could not have anticipated R1’s suicide, his
obvious and florid mental health problems were nevertheless serious enough to
warrant further vigilance in his supervision. I am not persuaded by Dr. Noble’s
testimony that R1’s problems presented no warnings of problems that would have
required enhanced supervision or monitoring.

As discussed above, Dr. Ziv testified that R1’s bouncing behavior for hours at a
time, his lack of sleep, and his troubling “microchip” delusion were clear
indications that R1 was further destabilizing. I note that, on cross-examination,
even Dr. Noble admitted that if someone with schizophrenia exhibits
hallucinations and delusions, he would be considered “actively psychotic.” Tr. at
596. In Dr. Ziv’s opinion, R1 exhibited behavioral signs of an increasingly
disturbed mental state, which should have prompted Petitioner’s staff to seek
further psychiatric evaluation of R1. I find Dr. Ziv’s opinion is consistent with the
APA Guidelines. The APA Guidelines state:

When treating individuals in long-term care facilities, the
psychiatrist should be mindful of the need for follow-up
assessments, even when initial evaluation does not show evidence of
depression or increased risk for suicide or other self-injurious
behaviors. To facilitate early intervention, safety and suicide risk
should be reassessed with significant changes in behavior,
psychiatric symptoms, medical status, and/or level of functional
disability.

‘6 Although Mr. Hoyes testified on cross-examination that he had reviewed the
exhibits in this case, it appeared that he was unfamiliar with the facts, for he
testified on cross-examination that he did not see anything in the record that
verified that the basis for R1’s accident was a suicide attempt. Mr. Hoyes said that
he had heard anecdotally that R1 had had an industrial accident. Tr. at 455-56.
30

CMS Ex. 38, at 124. I accept as credible and persuasive Dr. Ziv’s expert opinion
that, in the case of R1, his behavioral changes were serious and required follow-up
psychiatric care, i.e. a “face-to-face evaluation.” Tr. at 358.

Moreover, I find Dr. Ziv’s testimony that R1’s anxiety and agitation, as
manifested by his bouncing behavior, were signs that his mental state was
deteriorating and should have been viewed as more than symptoms associated
with his baseline schizophrenia, consistent with the APA Guidelines and therefore
credible. Dr. Ziv testified that R1’s bouncing behavior, which began on June 6,
indicated that R1 was becoming “increasingly unstable from a psychiatric point of
view.” I agree with CMS that Dr. Noble’s opinion that there is no relation
between agitation, as manifested by R1’s bouncing behavior, and the risk of
suicide, is contradicted by the APA Guidelines. As CMS points out, the APA
Guidelines state:

Anxiety appears to increase the risk for suicide . . . Specifically
implicated has been severe psychic anxiety consisting of subjective
feelings of fearfulness or apprehension, whether or not the feelings
are focused on specific concerns. Clinical observation suggests that
anxious patients may be more inclined to act on suicidal impulses
than individuals whose depressive symptoms include psychomotor
slowing. . . . In an inpatient sample, severe anxiety, agitation, or both
were found in four-fifths of patients in the week preceding suicide.

CMS Ex. 38, at 116.

Petitioner argues that CMS has given an “incomplete” quote from the APA
Guidelines, which is “at best misleading.” P. Reply at 21. According to
Petitioner, in an earlier section of the Guidelines, titled “Anxiety disorders,” the
APA states that there is “very little research” that shows a link between anxiety
disorders and suicide. Petitioner states that the APA “reported that anxiety
disorders may increase the rate of suicide in patients suffering from major
depression, but the link to increased suicide rates is ‘less clear’ with other
diagnoses.” P. Reply at 21. Petitioner notes that where there is an increased risk
of suicide, the APA stated that it may be associated with the comorbid diagnosis
itself, and not the anxiety disorder. P. Reply at 21. Petitioner thus asserts that Dr.
Noble is correct that R1’s anxiety in the days preceding his suicide did not
necessarily indicate an “increased risk beyond that associated with his baseline
schizophrenia” or necessitate “increased suicide precautions.” P. Reply at 21.

I find no merit in Petitioner’s claims that the APA Guidelines excerpt quoted by
CMS is “misleading” or ambiguous, or has limited value or meaning. CMS Ex.
38, at 116-17. In fact, at the end of the “Anxiety disorders” section of the APA
31

Guidelines relied upon by Petitioner, the APA states the following: “Nonetheless,
suicide risk may be diminished by identifying masked anxiety symptoms and
anxiety disorders that are misdiagnosed as medical illness as well as by explicitly
assessing and treating comorbid psychiatric diagnoses in individuals with anxiety
disorders.” CMS Ex. 38, at 113. There can be little doubt that, according to the
APA, there exists a correlation between anxiety/anxiety disorders and suicide risk.

Moreover, I find Dr. Noble’s testimony that it was “appropriate” for Petitioner’s
staff to let R1 go outside to smoke in the middle of the night to be disingenuous.
Dr. Noble testified that, based on R1’s mental state, his past behavior at
Petitioner’s facility, and the fact that he had not expressed any intention to harm
himself, there was no need to supervise R1 and no reason to be concerned. Tr. at
588. Dr. Noble appeared to contradict himself later, for, on cross-examination, he
acknowledged that if someone with schizophrenia experiences hallucinations and
delusions, “it would be fair to say” the person is “actively psychotic.” Tr. at 596.
Thus, based on Dr. Noble’s own testimony, R1 would be considered “actively
psychotic,” for, in addition to his severe bouncing behavior, R1 also had delusions
and hallucinations from June 7-10, 2009. P. Ex. 108, at 1; Tr. at 97. The most
serious of these delusions occurred on June 9, 2009, when R1 called his sister and
told her about his microchip delusion. Although Dr. Noble opined that R1’s
delusion was “very typical” of patients with paranoid schizophrenia and not a sign
that R1 was decompensating, R1’s psychiatrist, apparently after learning about
R1’s delusion from DON Powell the next day, ordered that R1’s morning dosage
of Clozaril be increased. Clearly, R1’s psychotic symptoms were not under
control. In testifying that there was no cause for concern when R1 went outside to
smoke, Dr. Noble chose to ignore the fact that, a little over an hour before going
outside, R1 had been bouncing so violently that he fell out of his wheelchair and
collapsed, shattered leg and all, to the ground. R1 was an actively psychotic
schizophrenic whose mental state had obviously worsened, and for Dr. Noble to
opine that R1 required no supervision when he left the facility after midnight is not
consistent with any reasonable standard of concern for R1’s safety.

With respect to CMS’s reliance on Dr. Ziv’s testimony, Petitioner asserts that
CMS has substituted Dr. Ziv’s after-the-fact opinions for the contemporaneous
judgments and first-hand assessments made by Petitioner’s physicians and staff.

P. Reply at 18-19. Petitioner notes that Dr. Ziv neither saw nor assessed R1, and
drew inferences and conclusions from “only portions of the paper record.”

P. Reply at 9. Moreover, Petitioner asserts that Dr. Ziv disregards the fundamental
distinctions between nursing facilities and psychiatric facilities.

Petitioner’s arguments are unavailing. Dr. Ziv’s expert opinions regarding R1
were based on careful review of the records, reflected her extensive experience
with psychiatric patients, and were consistent with the APA Guidelines. Given
32

that none of Petitioner’s witnesses who testified at the hearing had seen or
assessed R1, the fact that Dr. Ziv did not personally examine R1 has little
significance. Petitioner claims that Dr. Ziv reviewed only part of the record and
thus had an incomplete picture of R1; however, she reviewed the same documents
as Petitioner’s witnesses, and I do not find that her testimony was credibly
rebutted or refuted. I further find that whatever distinctions exist between nursing
facilities and psychiatric facilities are irrelevant to my examination of the issues of
this case.

The record and Dr. Ziv’s credible testimony establish that, given R1’s
increasingly-severe decompensation, it was imperative that Petitioner’s staff take
necessary precautions to protect him from foreseeable accident hazards and to
adequately supervise and monitor him. With the single exception of LVN Yoder,
however, Petitioner’s staff saw no urgency in the worsening of R1’s psychiatric
symptoms and failed to take appropriate action. Petitioner’s failure to supervise
and monitor R1 is nowhere more evident than on the night R1 left the facility,
unaccompanied by staff, determined to end a night of increasing agitation and
discomfort by ending his own life.

Petitioner inexplicably contends that R1’s leaving the facility was a harmless
event instead of recognizing the situation for what it plainly was -- an elopement.
According to Petitioner, R1 wheeled himself out to have a smoke, and did not
require any supervision since he had been assessed as a “safe smoker.” Petitioner
contends that there was nothing unusual about this and even asks what further
actions should have been taken: “At most, CMS asserts that it was unusual for
Resident #1 to be awake and wanting to smoke in the early morning hours, and
that instead of simply noting the fact, the nurse on duty should have . . . done
what?” P. Reply at 25.

Petitioner contends that R1’s death was neither “foreseeable” at that moment nor
“avoidable” by any reasonable intervention at that time. P. Br. at 38 (emphasis in
original). According to Petitioner, its staff could not have been expected to
anticipate the precise circumstances that led to R1’s committing suicide. In its
posthearing reply brief, Petitioner states, “In retrospect, it is obvious that had the
nurse accompanied the Resident while he smoked, then perhaps he might not have
responded to what must have been a sudden overwhelming impulse (or at least not
then, or by hanging himself from the fence). But even in retrospect, it is hard to
see how the nurse should have foreseen that specific risk, or the necessity to
intervene immediately to prevent it.” P. Reply at 25.

I find that Petitioner’s attempt to portray R1’s elopement as unremarkable
demonstrates an extraordinary indifference to its duty to supervise and keep R1
safe from accidents. There can be no question that when R1 wheeled himself out
33

of the facility in the middle of the night, unaccompanied and unsupervised — and
after the bizarre and disturbing features of his conduct and condition in the hours
immediately preceding his elopement — the risks to him were obvious and
foreseeable. I can conceive of no justification for Petitioner’s allowing an actively
psychotic schizophrenic with impaired decision-making abilities to wheel himself
out of its facility unattended, after midnight, while in an obvious state of acute
physical and emotional distress.

As discussed above, the duty of care owed by Petitioner to its residents under 42
C.F.R. § 483.25(h)(2) is not one of strict liability. However, Petitioner is required
to provide adequate supervision and assistance devices to prevent accidents.
Crestview Manor, DAB CR1350 (2005); Windsor Health Care Ctr., DAB No.
1902, at 5 (2003). It is evident here that Petitioner failed to provide adequate
supervision to R1; in fact, it provided no supervision at all.

While Petitioner’s staff might not have been expected to foresee the tragic event
that occurred, it could reasonably be expected to foresee that R1 was at risk of
suffering harm or other injuries if not adequately supervised. Batavia Nursing and
Convalescent Ctr., DAB No. 1905, at 45 (2004). The Board defined the concept
of “foreseeability” in the context of 42 C.F.R. § 483.25(h)(2) as follows:

The Board has held that assessing foreseeability, simply requires
looking at the “circumstances that were apparent or should have
been apparent to the facility and then evaluat/ing] whether those
circumstances — which can often be unique — were such that the
facility could reasonably have anticipated the possibility of harm to
the resident.” Lutheran Home at Trinity Oaks, DAB No. 2111, at 17
(2007).

Briarwood Nursing Ctr., DAB No. 2115, at 13, n.9 (emphasis added) (2007).
In Josephine Sunset Home, DAB No. 1908 (2004), the Board stated:

The regulation speaks in terms of ensuring that what is
“practicable” and “possible” to do is done. What is
thus required of facilities is not prescience but

reason and professional judgment in assessing what can
be done to make residents (given their special needs)
safe, through removing accident hazards, providing
appropriate devices, and ensuring adequate supervision.

Josephine Sunset Home, at 14-15 (2004).
34

The Board’s analysis is instructive in assessing the facts and context of what
happened with R1. R1’s history included a previous suicide attempt, he was a
schizophrenic, he had an obvious tendency toward risky behavior, he was assessed
to be cognitively impaired, and he showed signs of psychosis. Around 11:20 p.m,
a little over an hour before his leaving the facility, R1 exhibited bouncing behavior
so severe that he bounced himself out of his wheelchair and fell to the floor. It is
apparent that there existed an irrational and potentially dangerous shortfall
between his ability to assess risk and the real risks all around him. When R1 left
the facility premises ostensibly to smoke unsupervised in the middle of the night,
it was quite unlikely that he would have perceived the whole range of dangers to
which he could possibly have been exposed — even if his self-immolation was not
among them in that instant—and the facility staff had every reason to know that.
Petitioner has pointed out that R1 was assessed as an independent smoker who did
not require supervision, and while this may have been true when he was assessed
on May 22, 2009, his psychiatric condition had clearly changed in the two critical
weeks since then. One cannot imagine that, after R1 had crashed violently out of
his wheelchair during another bouncing episode, he would have been assessed to
be a “safe smoker.” There is no question that R1 was engaging in behavior that
put him at great risk when he wheeled himself outside, and it was Petitioner’s duty
to be proactive in its supervision of him.

I have no difficulty in concluding that when Petitioner’s staff saw R1 leaving the
facility, unaccompanied, they “could reasonably have anticipated the possibility”
that he could somehow come to serious harm. Yet they did not stop him from
going outside nor did they attempt to provide him with any supervision or
protection. The Board in Coqguina Ctr., DAB No. 1860 (2002), concurred with the
ALJ’s opinion that, with a foreseeable risk that a facility could have practicably
prevented, CMS did not have to show “that Petitioner foresaw the precise way in
which harm would be visited upon residents as a result of its facility’s failure to
comply with participation requirements” in order to support a deficiency finding.
Coquina Ctr., DAB No. 1860 (2002), at 20, quoting Coguina Ctr., DAB CR899
(2002), at 10. I find that Petitioner’s staff fell far short in its duty to take all
reasonable steps to ensure that R1 received supervision that met his assessed needs
and mitigated foreseeable risks of harm from accidents, and thus violated 42
C.F.R. § 483.25(h). Woodstock Care Ctr. v. Thompson, 363 F.3d at 589 (a SNF
must take “all reasonable precautions against residents’ accidents”).

Petitioner makes an additional argument that a state criminal investigation has
somehow hindered its presentation of its case. However, from the time Del Rosa
Villa was surveyed by the state agency to the time Petitioner claims it became
aware of the state criminal investigation, it had almost a year to research and
prepare its case. Every bit of evidence in its records, in the testimony of its staff,
or in the records of third parties, was freely available to it without restriction.
35

Reduction of any oral testimony to written statements would have been an obvious
measure in the most routine of situations. I regard it as particularly significant that
although Petitioner had notice of the criminal investigation at least by May 20,
2010 (see B. Gluck Declaration attached to Petitioner’s July 6, 2010 motion), Mr.
Gluck delayed executing his declaration until June 18, 2010, and Petitioner did not
bring the matter to my attention until its motion of July 6. Thus, at the outset and
at the end of any discussion of this point must lie this realization: whatever
evidence Petitioner now claims it was prevented from offering has, from the
beginning, been within its own control, and was for a substantial period not the
subject of criminal inquiry.

Petitioner has never offered any actual demonstration in fact of just how its case
development was hindered, but has only posed such claims in purely speculative
terms. There is no reason that Petitioner could not have attempted a concrete,
detailed proffer of what it might show if the showing were unimpeded by the state
investigation. Such a proffer could easily have been made on the basis of written
witness statements obtained early in Petitioner’s own preparation of its case. It is
very, very difficult to see Petitioner’s argument, continued as it was over weeks
and months beginning in the summer of 2010, as supported by a real problem not
of its own making.

2. The proposed per instance CMP of $10,000 is reasonable.

CMS determined to impose a per instance CMP of $10,000. CMS Ex. 40. The
regulation authorizes the imposition of a per instance CMP ranging from $1,000 to
$10,000. 42 C.F.R. § 498.438(a)(2). I must assess de novo the reasonableness of
the CMP proposed by CMS based on the factors set forth at 42 C.F.R. §
488.438(f). In determining the amount of the CMP, the following factors
specified at 42 C.F.R. § 488.438(f) must be considered: (1) the facility's history of
non-compliance, including repeated deficiencies; (2) the facility's financial
condition; (3) the seriousness of the deficiencies as set forth at 42 C.F.R.
§488.404; and (4) the facility's degree of culpability. The CMS determination
regarding the scope and severity of the deficiencies is not subject to my review, as
the scope and severity of a deficiency has no effect on the range of per instance
CMP which may be imposed. 42 C.F.R. §§ 498.3(b)(14), 488.438(a)(2); see 42
CER. §§ 498.3(d)(10)(ii), 488.438(c).

CMS submitted evidence that shows that Petitioner was previously found in
violation of 42 C.F.R. § 483.25(h) on each of its previous four re-certification
surveys in 2005, 2006, 2007, and 2008. CMS Ex. 10, at 8. It is evident that
Petitioner has a past history of noncompliance involving the failure to provide
adequate supervision. Petitioner has not provided any evidence to show that its
financial condition would preclude it from paying a $10,000 per instance CMP.
36

As discussed above, the deficiency citation is based upon an extremely serious
incident. Despite Petitioner’s insistence that what happened to R1 was not the
result of unreasonable staff judgments, actions or omissions, I find that
Petitioner’s culpability was substantial. The term “culpability” is defined at 42
C.F.R. § 488.438(f)(4) to include, but to not be limited to, neglect, indifference, or
disregard for a resident’s care, comfort, or safety. Petitioner’s staff exhibited
indifference and disregard for R1’s care and safety when they completely failed to
provide any supervision or monitoring whatsoever to R1 when he wheeled himself
out of the facility to his self-inflicted death, alone and in distress, in the middle of
the night.

Based on my consideration of the regulatory factors listed in 42 C.F.R. §
488.438(f), I find that the per instance CMP of $10,000 is reasonable. Petitioner’s
staff’s failure to supervise R1, who had become increasingly unstable mentally
and exhibited severe psychotic symptoms, resulted in tragic consequences.
Although the $10,000 amount is at the top of the range for a per instance CMP
under the regulations, I find it to be authorized and appropriate as a mechanism to
ensure future compliance and to protect Medicare beneficiaries.

V. Conclusion

For the foregoing reasons, I conclude that Petitioner failed to comply substantially
with federal participation requirements and that the per instance CMP imposed
against it is reasonable.

/s/
Richard J. Smith
Administrative Law Judge