Nursing Homes Fined For Patient Death, Failure To Administer Drugs

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Five nursing homes have been cited and fined by the Department of Public Health for patient care lapses, including an incident at Aurora Senior Living of Cromwell in which a resident with eating problems died after being given marshmallows.

According to the DPH, the resident was diagnosed with mental retardation, dementia, schizophrenia, diabetes and dysphagia and “required extensive assistance while eating’’ and “direct supervision during meals.’’  A visitor was given permission by a licensed practical nurse to give the resident two regular-sized marshmallows to eat.  The patient became unresponsive, and cardiopulmonary resuscitation was initiated.

The resident was transported to the hospital and died two days later.  The DPH citation notes that the nurse was not familiar with the diet restrictions for the patient.  The facility’s vice president of clinical services said “the expectation would be that the nurse would always refer to the physician’s orders in the clinical record.’’  The nurse was fired for failing to follow the doctor’s orders or the care plan, according to the citation. The facility was fined $650.

Other action by the state includes:

• The Apple Rehabilitation West Haven was cited after the state found that 15 patients who were being treated for various illnesses, including congestive heart failure, hypertension, depression, dementia, gastro-esophageal reflux disease and multiple sclerosis were not being given the correct daily dosage of medications.

Eleven of the residents did not receive the proper drug dosage for a year, according to the citation, which followed a February inspection.  In fining the facility $600, the state found that while each resident did not receive medication as prescribed, ‘’there were no identified adverse outcomes.”

• The Masonic Health Center of Wallingford was fined $815 after a state inspection found that two residents were injured while being transported in wheelchairs, and two other residents suffered sudden weight losses.  According to the citation, a nurse’s aide used a wheelchair without footrests to transport a patient who was identified as needing assistance in moving. The patient suffered an ankle injury when his or her foot was caught under the wheelchair.  The center’s director of nursing indicated that the nurse’s aide should have applied footrests to the chair before moving the patient. In the second incident, a patient fell out of a wheelchair and was injured while being transported down a hallway by a nurse’s aide.

The inspection also found that one resident had lost 17 pounds in 10 days, and a second patient lost 7 pounds in about a month.

• New London Rehabilitation And Care of Waterford was fined $510 after a resident was injured while being moved with a Hoyer lift. In addition, the state cited the facility for not properly monitoring the patient’s injury.

• Apple Rehabilitation Laurel Woods of East Haven was fined $510 when a patient was injured during a transfer in the bathroom.  A doctor’s order indicated that the patient should be assisted by two people, not one.