Eight Connecticut nursing homes have been fined by the state Department of Public Health for incidents involving lapses in care, including a failure to call 911 when a resident was dying and a case in which one resident attacked another with a butter knife.
On April 29, the Norwichtown Rehabilitation and Care Center was fined $1,160 in connection with a Feb. 23 incident in which 911 was not called when a resident with severe heart and kidney problems was found without vital signs, records show.
CPR was performed for five minutes before an advanced practice registered nurse ordered it stopped because the person had died, but a registered nurse mistakenly told the APRN that it had gone on for 15 minutes, records show. A doctor at the home said that a longer CPR session would not have saved the resident, but the home was faulted for not ensuring that 911 was called, records show.
Norwichtown’s administrator could not be reached for comment.
Trinity Hill Care Center in Hartford was fined $850 on April 16 in connection with a resident who had hit four other residents and tried to cut one of them with a butter knife, records show.
On Jan. 20, the resident, who has schizophrenia and a traumatic brain injury, struck two residents on the shoulders, records show. The abusive resident was hospitalized and his or her care plan was updated to include conflict resolution steps.
On March 3, the resident hit the same two residents in the face, causing one to be hospitalized for impaired vision, records show. The home’s records failed to document a nurse’s assessment after the incident, records show.
On March 7, the resident struck a third resident in the chest and admitted to using a butter knife to try to cut the person, records show. The abusive resident complained of hand pain and was hospitalized. The assistant director of nursing told state officials that he or she did not investigate the use of the knife as a potential weapon, and the care plan was not updated related to the resident’s use of metal utensils, state records show.
The resident returned to Trinity Hill, and one-on-one observation was ordered. In an unprovoked attack five days later, the resident knocked a cup of coffee out of a fourth resident’s hand and punched the person in the face, records show. That resident suffered a bruised right eye, and the abusive resident was hospitalized again. When he or she returned March 23, the home increased its monitoring of the person’s behavior and continued psychiatric care, records show.
Trinity Hill’s administrator, George Kingston, said that the home worked diligently with state agencies to find the person a more suitable placement.
Kingston added that the home implemented a proper plan of correction that was accepted by the state.
“Trinity Hill Care Center is committed to upholding the highest standards of care for its residents and takes these matters seriously,’’ he said.
On March 12, Village Crest Center for Health and Rehabilitation in New Milford was fined $1,090 for incidents in which a resident was verbally and physically abused and in which a resident was hospitalized after apparently being given the wrong medication, records show.
DPH records show that on Jan. 13, a nurse’s aide was observed providing “rough care” to a resident and was heard calling the person a derogatory name. An investigation by the home substantiated physical and mental abuse, and the aide, who denied any wrongdoing, was fired, records show.
On June 9, 2013, a resident recovering from knee surgery was re-hospitalized with blood in the urine, records show. The resident was not feeling well and had refused to take the medications that were being given and was found at the hospital to have “gastritis secondary to medications,’’ DPH records show.
The assistant director of nursing said he or she did not check that the resident’s name at the top of each page of a list of medications, and it was determined that the medication listed on the second page was for a different resident, records show.
Timothy A. Brown, a spokesman for Village Crest’s parent company, National HealthCare Associates, said that the home developed an action plan that addressed the areas of concern raised by the state. The plan, which included education and training of the staff, was accepted by the state, which found the home in compliance during a subsequent inspection, Brown said.
Ingraham Manor in Bristol was fined $1,160 on April 15 in connection with a resident who became lethargic and confused from apparent dehydration on April 2, records show. The director of nursing services at the home admitted the resident should have been screened for possible dehydration when he or she was not taking in enough fluid, records show.
A spokeswoman for Bristol Hospital, which owns Ingraham Manor, could not be reached for comment.
Wintonbury Care Center in Bloomfield was fined $1,020 on April 15 in connection with a resident who developed a severe pressure sore on a heel on April 2, records show. A state review of the home’s records found that a nurse’s care card failed to reflect that the pressure sore existed and that a shoe should be kept off and the foot should be elevated or padded, records show.
On April 2, a nurse’s aide who was unaware of the sore put a shoe on the resident’s foot, records show. That day, staff members discovered that the resident’s injury had worsened, and a doctor subsequently ordered that the resident should wear a foam boot, records show.
Wintonbury’s administrator could not be reached for comment.
On April 8, Skyview Center of Wallingford was fined $290 in connection with a resident with dementia, who left the center March 15, probably through a window, and was found uninjured four hours later by police, records show.
When the resident had sought to leave the home March 9, a doctor had ordered a psychiatric consultation, but DPH records show the consultation was not done until March 20, after the resident had “eloped” from the home.
The state found the home’s records failed to reflect that the morning of March 15, the person had exhibited “exit seeking behavior” by putting on his or her coat and saying he or she was going to see a spouse, records show.
Skyview Center was cited for deficiencies relating to the incident, but the resident was found safe and unharmed, spokesperson Jeanne Moore said.
“We worked with the state survey agency and very quickly regained regulatory compliance,’’ she said.
On May 9, Masonicare Health Center of Wallingford was fined $290 in connection with a failure to supervise a resident who was found lying on the floor in a smoking room on March 29. The resident was sent to an emergency room and returned to the home the next day with no new injuries, DPH records show.
Records show a licensed practical nurse and a nurse’s aide were disciplined for failing to supervise the resident, and a receptionist who did not check a camera monitor of the smoking room quit. The home retrained employees and now requires the new receptionist to check the smoking room camera monitor every 30 minutes, records show.
Margaret Steeves, a spokeswoman for Masonicare, said that the home’s staff thoroughly reviewed its policies and procedures and retrained its staff after the incident.
“Masonicare Health Center takes resident safety very seriously,’’ Steeves said. “This unprecedented incident was thoroughly investigated by management.”
Abbott Terrace Health Center in Waterbury was fined $1,370 on May 12 in connection with the smoking habits of six residents. State records show that there was no evidence that smoking assessments had been done on the residents or that a system was in place for residents to return smoking materials to a nursing station.
DPH records show the home later revised its policies, required one resident to wear a “smoking apron” for safety, imposed designated smoking hours outside the home and had smoking materials stored in a locked box.
Abbott’s administrator could not be reached for comment.