October 12, 2011

Hartford Elder Care Home Cited In Resident’s Death

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A Hartford rest home will be monitored by a special consultant, after a June incident in which a resident set himself on fire and died while the home’s overnight attendant was asleep in her room.

Fernwood Manor on Girard Avenue has agreed to hire an independent consultant to oversee its fire safety, staffing and resident monitoring policies, under a consent order issued Sept. 30 by the state Department of Public Health. The DPH is requiring the home to tighten its resident supervision policies, train staff in those rules, and ensure that the facility has “sufficient personnel” on duty to monitor residents, the consent order says.

The home also will pay a small fine – $500 – for failing to ensure that the resident who died “was supervised in a manner that prevented injury,” according to the DPH order.

An inspection report in July found that the Fernwood Manor staff failed to properly monitor residents in the overnight hours of June 19. The home has an 11 p.m. curfew, by which time residents are supposed to be settled in their beds, the report says. An overnight attendant is supposed to make rounds to check on the residents overnight, as well as to ensure that all doors are locked.

Instead, a group of six residents was reportedly wandering in and out of the building after midnight and gathering on the front porch to smoke. Sometime after 4 a.m., one of the residents’ clothes caught fire, and other residents called the police. The resident died of injuries related to the fire.

The attendant on duty told DPH inspectors that she was resting in her room and did not make rounds after the curfew. Instead, she was alerted after the police were called.

She told inspectors that the resident who died had “played with a lit cigarette all the time on his clothing and on his skin, and [she] had seen this with her own eyes. .. She identified that other staff knew and did not tell anyone because [the resident] would say he was just playing around.”

Administrators of the home said attendants are supposed to stay awake and make rounds, but that the facility had relied on the “honor system” to make sure that happened.

The DPH report says that after the fire, burn holes were found in some of the clothing that had been worn recently by the resident, including a jacket and shorts.  Administrators said they were not made aware of reports that the resident had previously burned himself with cigarettes.

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