May 23, 2014

Nursing Homes Cited After Two Residents Died, Another Sexually Assaulted

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Seven Connecticut nursing homes have been fined by the state Department of Public Health in connection with lapses in care, including one sexual assault of a resident by another resident and two cases in which residents died.

Other cases involved residents who developed pressure sores, one who sustained a cut on the forehead during a fall and another who left a home and wandered across the street.

The Kent Ltd. of Kent, which is owned by Apple Rehab, was fined $1,195 on April 4 in connection with two residents for whom CPR was delayed or stopped without a doctor’s order, records show.

On May 5, 2013, there was a delay of nine minutes in starting CPR on an 88-year-old resident while a supervisor was notified and while equipment was gathered, records show. The former director of nursing services said he or she got a call from a staff member saying that a doctor had ordered the CPR to be stopped, but the doctor later said he or she would not have given such an order over the phone, records show.

The resident died, William Gerrish, DPH’s spokesman, said.

On Nov. 22, a 73-year-old Kent resident died in a case in which CPR was stopped without a physician’s order, records show.

Ann Collette, an Apple spokeswoman, said both residents were hospitalized and that neither died at The Kent. She said the facility is continuing to educate its staff and to review its procedures by holding mock “code” drills.

“Kent nursing staff has [been] given extensive education on conducting codes, ensuring nurses know how to react [in a] timely [way] in emergency situations,” she said.

The home was also cited in connection with a resident soiling him or herself on Feb. 25 because gaps in communication led aides who were busy with other duties to fail to assist the resident, records show.

Brightview Nursing and Retirement Center in Avon, another Apple Rehab home, was fined $1,510 on April 23 in connection with a resident who became dehydrated after a delay in treatment, DPH records show.

DPH records show there was not an assessment of the resident’s hydration levels from Jan. 1 to Jan. 8, and that a doctor’s order for lab tests was made on Jan. 3, but not carried out until Jan. 7.

Collette said the citation involved a resident who received IV fluids at Brightview and was hospitalized for an unrelated medical condition. A dehydration assessment was completed and the doctor was notified 48 hours later, she said. The resident recovered, she said.

“The citation was the result of an oversight on [the] part of a nurse and remains an isolated incident,’’ said Collette, who added that all of the nurses were trained in the timely reporting of changes in a resident’s condition.

Orange Health Care Center was fined $1,420 on March 20 in connection with the sexual assault of one resident by another, records show.

A resident with schizophrenia who had already been found to have inappropriately touched a staff member was found on top of another resident on the floor by the second resident’s bed on Dec. 16, records show. The resident who was assaulted was hospitalized and treated for bruises, records show.

On the day of the assault, the staff failed to make its required checks of the second resident every 15 minutes, DPH found.

Orange Health Care’s administrator could not be reached for comment.

Cassena Care of Norwalk was fined $1,370 on March 24 in connection with lapses in care of two residents.

In February, a resident was hospitalized for weakness and abdominal pain. DPH records show the resident had bowel problems that were not reported to a nurse before the hospitalization occurred.

Also in February, a resident with a pressure sore did not receive morphine sulfate for three days despite a doctor’s order that the resident should receive the medication, records show.

A Cassena official declined to comment.

Highview Health Care Center of Middletown, a third Apple Rehab home, was fined $1,160 on April 28 in connection with the cases of three residents who developed pressure sores.

A resident who was recovering from a hip fracture in February developed a sore on a heel, and the home failed to document that the heels were properly elevated, records show.

In the case of another resident who developed a pressure sore on a heel in February, a doctor said the sores developed because the heels were not properly elevated, records show. DPH records show the facility was aware it had a problem with the prevention of pressure sores and not elevating heels.

In March, the director of nursing services signed a weekly pressure documentation without having looked at another resident’s pressure sore because of other duties, DPH records show.

Collette, the Apple spokeswoman, said the citation was related to an issue of ensuring that residents who are at risk for skin breakdown are properly “off-loaded.”  That involves positioning the resident so as to remove pressure from the heels, she said. Highview has updated its care plans and educated its staff on the importance of off-loading, she said.

Ingraham Manor, which is owned by Bristol Hospital, was fined $360 on March 31 in connection with a resident with dementia who left the home on Feb. 25 and walked across the street.

 

The person was located within five minutes of an alarm sounding. DPH said the home’s records failed to document that the person was at risk for leaving the home and staff members reported that they thought the resident could not walk that far unassisted.

 

Chris Boyle, a Bristol Hospital spokesman, said the home has since strengthened its procedures for identifying residents who are at risk for “elopement.”

 

“We have enhanced our security measures to better monitor the movements of our residents, and we also had a full re-survey from the Department of Public Health which indicated full compliance,’’ Boyle said.

 

Pope John Paul II Center in Danbury was fined $1,090 on March 25 in connection with a resident who fell from a shower chair on June 4, 2013 and sustained a cut on the forehead that required 14 stitches to close, records show.

 

The resident leaned forward, loosening a Velcro belt on the chair, while a nurse’s aide was reaching for a washcloth, records show. The home subsequently changed the resident’s care plan to require two aides to assist the resident in the shower.

The home’s administrator could not be reached for comment.

 

 

 

One thought on “Nursing Homes Cited After Two Residents Died, Another Sexually Assaulted

  1. ​What we’re reading about here is the future. Maybe your future. There is one prominent palliative care doc (Ira Byock) who has even said that if we look at nursing homes now, they are going to be like the Taj Mahal compared to what is coming down the pike, and there are always going to be nursing homes. Remember too big to fail? The issues involving eldercare and aging are apparently too big even to consider. There is too much money involved, too much about aging that we’d rather not think about, not to let the insider mentality of professionals, politicians, and speculators take charge and tell us everything is fine. The politicians go to industry events and are given awards for being “elder advocates” by industry officials who stand in the way of almost every reform – from both sides of the aisle. ( see “Law and Lobbying firm of Ritter and Cafero Sparks More Controversy” 5/3/14 Hartford Courant.) Connecticut hasn’t seen an incease in the staffing requirement – (the real source of many problems – in over thirty years.) There are always the bad apples we are told, the nursing homes down the road …. the deplorable conditions of other states, but the fact is that these kinds of circumstances recurr on a regular basis, and they are, according to a federal report issued this March by the Department of Health and Human Services, preventable. One in three residents are harmed by care lapses nationally. The answer: no more reports. Due to bugdet cutting the Inspector General’s Office announced that it won’t be making any more studies on this subject. Meanwhile we have politicians who take lobbying money from the industry as in the recent state session, who say they don’t have to announce this while making speeches against reform. Why should they? – apparently all papers are legally on file. We have former governors who accept illegal funding ($ 35,000) to advise a legislative campaign for a nursing home chain owner’s wife, and in the current session, a Republican, Cafero mentioned above , who works for a lobbying firm which is the same firm as a former Democratic speaker of the house (Ritter) is employed by, a firm that did 55,000 dollars of work for the nursing home association between 2012 and 13. ( see 5/3/14 Hartford Courant.)
    What can you say about a $1000. fines for a preventable human harm and death? A 2012 Pro Publica piece described the great inconsistency of fines between states. Among the most common violations in its research was the failure to follow doctor’s orders or care plans. Two states were used as examples at the low and the high end of the spectrum. In a 2012 Texas case, when a resident choked on a cookie the Center for Medicare Services approved a fine recommended by the state of $9500, but in contrast a North Carolina home in the same year was fined $350,000 for not providing care to a resident who died when removing a breathing tube. Both of the homes had been cited for “failing to operate in a manner that maintains the well being of each resident,” a charge which certainly could have been applied to circumstances described in the current story. And In Connecticut?: In January of this year a nursing home resident died of a preventable choking and a home was fined: $1040. After a recent report of a rash of theft by employees from nursing home residents a state official was quoted that it is families that must undertake “due diligence” when selecting a nursing home, but how can they? -What you will find that measures which determine the quality rating on the Nursing Home Compare website are based on a once a year inspection and data that is voluntarily provided by the homes and not verified by anyone. Some of the most highly rated homes also recieve the worst deficiencies. One elected official in a debate last year about prisoners and nursing homes was quoted as saying nursing home residents often don’t know where they are… but it appears that it is the public, the politicians, and the journalists who are the ones who are insensible to the real conditions which amounts to ignoring human suffering.

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