Four Nursing Homes Cited, One After Resident Dies

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Four nursing homes have been fined by the state Department of Public Health in connection with incidents in which one resident died, another was verbally abused and several female residents were touched inappropriately by a resident.

On March 13, 2014, Ledge Crest Health Care Center in the Kensington section of Berlin was fined $780 in connection with a March 2013 incident involving the resident who died.

Records show the resident had chronic constipation and was supposed to be monitored for abdominal discomfort and vomiting. Despite the vomiting and low blood pressure on March 4, 2013, a nurse’s note failed to say whether a doctor had been notified about the change in the resident’s condition and failed to show whether additional blood pressure checks had been done, DPH records said.

State records report that six hours later, the resident was admitted to a hospital for gastrointestinal bleeding and sepsis, a life-threatening inflammation prompted by an infection. The nursing home resident died,  William Gerrish, DPH’s spokesman, said.

Ann Collette, a spokeswoman for Apple Rehab, which owns Ledge Crest, said a doctor was in the center the day the resident was transferred to the hospital. The nurse who failed to document the doctor notification and all other licensed staff members have been educated about the importance of documenting such notifications when a resident’s condition changes, she said.

Westport Health Care Center was fined $1,160 in an amended citation on March 4 in connection with the case of a resident with dementia who had two falls, resulting in a broken arm and a cut scalp, DPH records show.

The resident had fallen and broken an arm after being left unattended in a bathroom, a nursing supervisor said told state officials in December 2013. The resident, who often refused to wear a protective helmet, had also been found bleeding on the floor on Jan. 31, 2013, records show. The resident was transferred to an acute care facility and was diagnosed with seizures and a cut on the scalp, records show.

DPH found that the center lacked documentation to show that interventions were in place to prevent the resident from sustaining a head injury.  An administrator at the Westport home declined to comment.

On March 24, Aaron Manor Nursing & Rehabilitation Center in Chester was fined $1,090 in connection with two incidents, including one in which a resident with dementia repeatedly touched and kissed female residents, records show.

Several times between April and August 2013, the resident was found to have rubbed the shoulders, chest, neck, leg or backside of the residents, records show. The resident also kissed one female resident on the cheek and another on the mouth, records show.

Each time, the home intervened by monitoring the resident every 15 minutes or ordering psychiatric evaluations or changes in medication, including administering drugs to reduce the resident’s testosterone and sexual function, records show. An evaluation determined the resident’s behavior was not sexual in nature and the person was not a danger to others, records show.

On Aug. 24, in the last incident, the resident tried to unbutton a woman’s shirt, records show. DPH concluded that while the home intervened after each incident, the interventions failed to ensure that the resident was monitored or adequately supervised to prevent inappropriate behavior.

The second incident at Aaron Manor occurred April 29 when a resident with dementia was found slumped in a wheelchair and bleeding from a large cut on the leg, records show. An investigation found that the chair’s leg rest was unlatched and the resident was cut when he or she slid out of the chair, records show. The resident received a new wheelchair, and aides were trained to be sure that leg rests were locked in place, records show.

Aaron Manor officials could not be reached for comment.

On March 4, Noble Horizons of Salisbury was fined $220 in connection with a Feb. 13 incident in which a nurse’s aide verbally abused a resident and left the resident alone and naked in a shower, records show. The resident, who has Alzheimer’s disease, was not injured but was “very weepy and upset,” records show. The home found that verbal abuse and neglect had taken place and fired the aide, records show.

Noble Horizons officials could not be reached for comment.