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.