April 21, 2016

Two Nursing Homes Fined After Deaths, Four Others Cited

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Six Connecticut nursing homes have been fined for violations, including two that resulted in resident deaths.

The state Department of Public Health (DPH) has fined Madison House in Madison $2,265 for an incident in which a resident was found face-down and unresponsive in bed.

The resident was admitted to the facility in November 2015, according to DPH, with a broken hip. The resident had surgery and subsequently went into cardiogenic shock five days later and required “extensive care,” according to the citation.

The resident was found unresponsive Dec. 26 and resuscitation attempts were unsuccessful. An investigation found that documentation failed to show that nurses notified a physician that the resident had been short of breath and needed oxygen on Dec. 24.

The facility worked with DPH and “very quickly regained regulatory compliance,” said spokeswoman Jeanne Moore. “Madison House is committed to providing quality care to its patients and residents.”

Montowese Health and Rehabilitation Center in North Haven was fined $1,950 for an incident in which a resident was injured in a fall and died two days later.

In November 2015, a resident with chronic kidney disease and other ailments was admitted. A consent form signed for the use of enablers, which help the resident turn and move in bed, didn’t specify how many side rails were to be used on the bed, according to the citation.

The resident fell from bed onto the floor Nov. 25 and suffered a blood clot in the brain and other injuries. The resident was treated at a hospital, readmitted to Montowese and was found on the floor Nov. 27 with no cardiac activity, according to DPH. Officials at the facility did not return a call seeking comment.

The DPH cited St. Joseph’s Center in Trumbull twice.

In one case, the facility was fined $1,060 for two instances in which residents didn’t receive timely incontinence care.

In October 2015, a resident with end-stage renal disease complained that the wait for incontinence care took more than an hour, according to the citation.

Then in December 2015, a resident with quadriplegia and other illnesses complained about not receiving incontinence care “in a timely manner.” The resident reported that a nursing assistant became argumentative about the lack of care.

In a separate citation, St. Joseph’s was fined $2,580 for an October 2015 incident in which DPH found insufficient documentation was kept.

Lab work showed a resident had an abnormal level of Dilantin, a prescribed anti-seizure medication, but documentation did not reflect whether the resident’s doctor was aware of the abnormality. The resident was taken to a hospital emergency department where it was determined the resident suffered “a breakthrough seizure” due to having a sub-therapeutic level of Dilantin.

St. Joseph’s Center worked with state inspectors to become compliant and strives to provide quality care to its residents, said spokeswoman Jeanne Moore.

Riverside Health and Rehabilitation in East Hartford was fined $3,000 for two violations, including one in which a resident did not receive incontinence care for more than five hours.

In September 2015, according to the citation, a resident requested help with incontinence care from a nursing assistant and went 5.5 hours without care. The resident was supposed to receive incontinence help every two hours, according to the care plan.

Also at the facility, a Feb. 29, 2016, inspection found 12 of 17 residents in a unit were not wearing identification bands as is required.

“Riverside is confident that the issues raised in the report were isolated and not consistent with the care and customer service at our center,” said spokesman Timothy Brown. “We have retrained the staff involved in policies, procedures and expectations for our customer service standards.”

Village Crest Center for Health and Rehabilitation in New Milford was fined $1,950 after a resident’s hand was cut and needed eight sutures.

The resident, who suffered from dementia, became agitated while showering and was hurt after grabbing the shower head and swinging it around, according to DPH.

An investigation found the nursing assistant helping the resident shower should have stopped the shower to report the incident, but didn’t, and that the resident’s aggressive behavior was not documented.

An administrator at the facility, run by New Milford Crossings LLC, could not be reached for comment.

Noble Horizons in Salisbury, was fined $540 for a February 2016 incident in which a witness saw a nursing assistant pull the arm and three times slap the face of a resident, according to DPH. The nursing assistant subsequently was fired, according to the citation.

Facility administrator Eileen Mulligan said no harm was done to the resident and it was “a one-time, unpredictable event.”

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