December 4, 2015

Nursing Homes Fined Following Resident’s Death, Lapses In Care

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Five nursing homes have been fined by the state Department of Public Health, including an Apple Rehab home in Old Saybrook that was fined $1,090 in connection with a resident who died of complications from pelvic fractures after falls at the home.

The resident lived at Apple Rehab Saybrook, and a medical examiner ruled the death an accident, the DPH citation dated Tuesday said.

On July 31, the resident was found on the floor, yelling, with a bruise on a wrist.

On Aug. 4, the resident was seen by a doctor for abdominal pain and a temperature of 100 degrees. A day later, the resident complained of discomfort in the hip and abdomen and had a bruised groin, the citation said. On Aug. 6, a doctor ordered a hip X-ray, which was normal. On Aug. 8, the resident was found sitting on the floor with no injuries.

Two days later, the resident was transferred to an emergency room and then a second hospital and was diagnosed with several fractured ribs and a fractured pelvis, the citation said. The person died there, and the cause of death was complications from a blunt injury to the torso with pelvic fractures, the citation said.

DPH found that a registered nurse failed to document that interventions were in place to prevent further falls after the resident had fallen July 31, the citation said. The nurse also failed to note that the resident repeatedly attempted to climb out of bed.

Ann Collette, an Apple Rehab spokeswoman, said the home’s staff was re-trained after the incident. She said, “Patient safety and fall prevention policies and protocols [were] reviewed with all staff and remains part of our ongoing staff education and quality improvement initiatives.”

The state also found in September that the water temperature in four bathrooms at the home was too high, at 134 degrees.

In a separate citation on Oct. 29, the same home was fined $210 in connection with a resident who was burned on the thighs March 24 when spilling hot soup.

DPH found that a licensed practical nurse failed to notify a shift supervisor or doctor of the incident and failed to document it. The same nurse did not monitor the injury for seven days, and the home did not obtain a treatment order from a doctor for seven days, the DPH citation said.

Another Apple Rehab nursing home, Laurel Woods in East Haven, was fined $1,440 on Oct. 15 in connection with three residents who developed pressure ulcers.

In one case, DPH found that four of five weekly body audits of a resident were not completed between July and September, the citation said.

In another case, a nurse’s aide forgot that a resident was not supposed to wear shoes and put sneakers on the person, the citation said.

On Sept. 14, DPH found that the water temperature in one room was 236 degrees. The problem was fixed within two days, the citation said.

Collette said the homes have taken action in response to the citations.

“All policies and procedures regarding patient safety as well as policies regarding the prevention of skin breakdown and wound care have been reviewed with staff,’’ she said.

“Water temperatures in all centers have been tested and are within normal limits and meet code.

Other recent DPH citations include:

The Springs at Watermark East Hill in Southbury was fined $1,370 on Aug. 26 in connection with a resident who developed a pressure blister on a heel. A licensed practical nurse was observed cleaning the person’s heel without washing hands between different steps of the treatment and without sanitizing scissors, DPH found.

The nursing home was also cited after a resident fell June 12 and broke a hip. DPH concluded that a required investigation of the fall was not completed and that the resident’s care plan was revised after the resident was found on the floor five times before June 12. Administrator Vitaly Polikoff could not be reached for comment.

On Feb. 17, Rosegarden Health & Rehabilitation Center in Waterbury was fined $1,230 in connection with a resident who sustained second-degree burns on an arm, hand and foot Jan. 26 when boiling water in a microwave.

After the burns, the kitchen was locked. DPH found that although the resident had a history of not following safety rules, the home failed to supervise residents or provide devices that would have prevented the second-degree burns.

Administrator Veronica Cretella declined to comment.

On Oct. 29, Pierce Memorial Baptist Home in Brooklyn, Connecticut was fined $1,095 in connection with a resident who developed a pressure sore on the heel Oct. 8. A registered nurse and the director of nursing services determined that interventions should have been in place to prevent skin breakdown when the person was admitted on Oct. 3.

In the case of another resident who developed a pressure sore, the director of nursing services was unable to find documentation that the wound had been re-evaluated or treated between Sept. 8 and Sept. 22, the DPH citation said.

Laura Crosetti, the home’s new administrator, said Pierce has made improvements since the incidents.

“Following the most recent inspection, we have initiated improved protocols related to skin care for our residents to ensure the best possible quality of care,” she said. “The residents involved are doing well following the attentive care received, and Pierce plans to continue to ensure our knowledgeable staff have the necessary resources to provide our patients with the state-of-the-art care they deserve.”

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