September 10, 2015

Five Nursing Homes Fined Following Lapses In Care

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The state Department of Public Health (DPH) has fined five nursing homes for violations, most of which resulted in injuries to residents.

The Springs at Watermark, East Hill, Southbury, was fined $1,300 after two residents were injured.

In September 2014, a resident who required an ankle and foot orthotic for transfers and walking – suffered a skin wound due to improper use of the orthotic, according to the DPH. An investigation found that the resident’s care plan lacked documentation about the use of the orthotic, according to the citation.

Also, in July 2015, a patient with various diagnoses, including anxiety and a history of falls, was hurt in a fall while being helped to the bathroom, according to the DPH. A nursing assistant was helping the resident to the bathroom, with the use of a rolling walker, when the nursing assistant stepped about a foot ahead of the resident to open the bathroom door and the resident fell, according to the citation.

In a separate citation, The Springs at Watermark, East Hill was fined an additional $1,160 for lapses in communication pertaining to a resident who suffered increasing ankle and hip pain and increasing inability to walk, according to the DPH.

In March, a resident with multiple diagnoses, including dementia and osteoarthritis, complained of left ankle and hip pain. Over the course of several days, the resident’s physical therapist noted that the pain was increasing and that the resident had lost the ability to bear weight on the left leg, according to the citation.

Nurses’ notes covering a three-day span, however, failed to document whether the resident’s physician was made aware of the physical therapists’ assessments, according to the citation.

“The Watermark East Hill was made aware of deficiencies by the state Department of Public Health and immediately developed a plan of correction, which was accepted and approved by the state,” officials at the facility, which is owned by Watermark Retirement Communities of Connecticut, said in a statement.

“We work hard each and every day to provide quality care and will continue to do so by providing each of our residents with a safe, comfortable and nurturing environment,” the statement said.

Montowese Health and Rehabilitation Center, North Haven, was fined $1,230 after a resident suffered a pressure ulcer on the leg due to staff’s use of a knee immobilizer, according to the DPH.

A resident was admitted in November 2014 with a broken right leg. The care plan called for the use of an immobilizer, according to the citation. Records indicate that staff placed the immobilizer on the resident before the resident went to sleep but the records do not indicate when the immobilizer was removed, according to the citation.

The resident suffered a pressure ulcer as well as a red and tender Achilles tendon and heel, which were determined to be caused by the immobilizer. The resident’s physician said staff had noticed the resident’s skin becoming red and tender earlier but failed to notify the physician, according to the citation.

Officials at the facility did not respond to a call seeking comment.

Fairview, Groton, was fined $1,160 after a resident suffered a leg wound requiring sutures while being transferred from a wheelchair into a bed, according to the DPH.

In June, two staff members were helping to move a resident with impaired mobility due to “fragile skin” from a wheelchair into a bed. According to the citation, staff failed to place required “derma savers” on the resident’s legs and the resident hit one leg on a bed rail during the transfer, resulting in a laceration that exposed tissue and required a dozen sutures.

Following the incident, a nursing assistant was educated in how the injury could have been prevented, according to the citation.

“We have a very strong track record of excellent quality care and whenever there’s an incident we take it very seriously,” said administrator James Rosenman.

While the facility’s staff disputed certain allegations of the citation, he said, Fairview submitted a correction plan to the DPH, “reviewed our internal processes immediately and made changes very quickly.” The DPH accepted the correction plan, he said.

Village Green of Bristol Rehabilitation and Health Center, Bristol, was fined $1,090 due to violations affecting two residents, according to the DPH.

In one instance in April, a resident with severe cognitive impairments and requiring two-person assistance to move in bed, fell and was injured when a nursing assistant tried to move the patient without help, according to the citation. The resident suffered skin tears to the nose, forehead and cheek, as well as facial swelling, according to the citation. The nursing assistant subsequently was fired, according to the DPH.

In a separate incident in April, a resident identified as being at risk for wandering left the building several times—including a trip to the “corner store”—when preventative measures failed. The resident was able to leave, in part, because a door alarm was not functioning, according to the citation.

Officials at the facility, which is owned by Subacute Center of Bristol LLC, did not respond to a call seeking comment.

Smith House Skilled Nursing Facility, Stamford, was fined $1,020 after a resident fell out of bed and was injured.

In February, a resident who was diagnosed with dementia and paranoid schizophrenia and was identified as a fall risk suffered lacerations on forehead and elbow from the fall.

A nursing assistant at the facility reportedly had bathed the resident and was about to request help to transfer the resident when the resident’s roommate asked for assistance, according to the citation. The nursing assistant reported helping the roommate for about two minutes, and hearing a crash, found the resident had fallen out of bed and hit the nightstand, according to the DPH.

An investigation revealed that when the nursing assistant went to help the roommate, precautions to prevent the resident from falling were not taken, according to the citation.

Officials at the facility, which is run by the city of Stamford, did not respond to a call seeking comment.

 

2 thoughts on “Five Nursing Homes Fined Following Lapses In Care

  1. My wife has been at Pendleton Nursing Home in Mystic Ct. and she has be dropped two times while being transferred from her wheel chair to the bed and vise verse. Thank God she was not seriously injured. Both falls she was taken to get x-rays and never got the results.

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