January 12, 2016

Five Nursing Homes Fined Following Two Deaths, Lapses In Care

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Five nursing homes have been fined at least $1,000 each by the state Department of Public Health in connection with lapses in care, residents who fell and broke bones and two residents who died.

On Dec. 2, Water’s Edge Center of Health & Rehabilitation in Middletown was fined $1,160 in connection with a resident who died within days of falling out of bed at the home on Nov. 16. Though a care plan called for two staffers to turn the resident in bed, only one nurse’s aide was turning the resident when the fall occurred, DPH’s citation said.

The resident was bleeding heavily and hospitalized with broken facial bones and a broken spinal bone, DPH’s citation states. The person was transferred to a hospice unit and soon died.

The aide was fired for not following the care plan, DPH said.

Timothy A. Brown, a spokesman for National Health Care Associates, which owns Water’s Edge, said the home conducted an internal investigation of the incident, which resulted in the employee discipline and staff re-training.

“Water’s Edge Center for Health & Rehabilitation takes the care and safety of its patients and residents very seriously and has a zero tolerance policy to any type of lapse of care,” he said.

On Nov. 30, Miller Memorial Community’s Edward Pavilion-Caroline Hall in Meriden was fined $1,370 in connection with the care of four residents, including one who died.

The 93-year-old resident and family members had requested a “do not resuscitate” order, but the order was not entered into the home’s computer system, DPH said. On June 5, the resident was found without a heartbeat. CPR was performed and the resident was intubated by paramedics and hospitalized on advanced life support, but then died, the DPH citation states.

The home was also cited in connection with a resident who fell out of a wheelchair and broke a hip when a nurse’s aide pulled on the chair, DPH’s citation states. The aide received a written warning for not ensuring the resident’s safety, the citation said.

The citation also involved an incident in which a registered nurse was three hours late in giving a resident medication for severe pain.

The home was also cited in connection with a resident who went six days without a bowel movement in September and the home failed to implement its standard bowel treatment before the person was hospitalized, DPH found.

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

On Dec. 23, Southington Care Center was fined $1,020 in connection with a resident who fell out of a chair on Aug. 29 and sustained an acute head injury, the DPH citation states.

When the resident repeatedly tried to get out of a bed or chair without help, the home placed the person on one-to-one observation but then switched to monitoring the resident every 15 minutes. The DPH citation states the home failed to assess the resident to make sure the monitoring could safely return to every 15 minutes.

Tina Varona, a spokeswoman for Hartford HealthCare, said after the fall, the home’s staff was provided additional training on conducting a fall risk assessment. Southington Care Center is part of Hartford HealthCare Senior Services.

“At Hartford HealthCare, we take complaints and concerns seriously and work diligently to rectify all matters,” she said, adding that “chart audits will be performed on all residents who will be assigned to one-on-one supervision to ensure that a fall risk assessment has been conducted and documented.”

Apple Rehab of Guilford was fined $1,020 on Dec.1 in connection with a resident who fell and broke a leg at the home June 12. The resident then developed a pressure sore under a leg splint because the splint was not removed for three months, DPH’s citations states.

The orthopedist who had seen the resident said that if the nursing home had contacted him or her, the staff would have been directed to open the splint and inspect the skin each day, the citation states.

Apple Rehab’s spokeswoman could not be reached for comment.

Edgehill Health Center in Stamford was fined $1,160 on Aug. 27 in connection with three residents with pressure sores.

In May, the home failed to document that a resident’s pressure sore was thoroughly assessed as the sore worsened over 17 days, the DPH citation states.

The fine was also imposed in connection with another resident who had a pressure sore who was not repositioned or provided incontinent care during three hours on Aug. 5, DPH’s citation states.

In another incident in August, the home did not provide a pressure-relieving cushion for a wheelchair for a resident and failed to document that a doctor and dietician were notified of the pressure sore, DPH found.

Christopher Barstein, executive director of Edgehill, said the home submitted a plan of correction to DPH on Sept. 16. DPH returned to re-inspect the home on Sept. 25 and found it to be in full compliance, he said.

“Submission of a plan of correction does not constitute an agreement with their findings,” he said.

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