May 12, 2016

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

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Six nursing homes have been fined in connection with one resident who was physically abused, one who broke a leg and one who was hospitalized with severe dehydration and later died.

In two state Department of Public Health [DPH] citations on Dec. 7, Touchpoints at Farmington was fined a total of $2,810 in connection with a resident who was hospitalized in May 2015 in intensive care with severe dehydration and then transferred to hospice care.

Maura Downes, DPH’s spokeswoman, said the resident died more than two weeks after the incident, but DPH officials were not able to “substantiate causation between the incident and the resident’s death.”

The home was fined $1,580 in connection with the resident’s decline in fluid intake over eight days in May 2015. The home’s records failed to show that a doctor had been notified about the resident’s fluid intake, the citation said.

In the second citation, Touchpoints was fined $1,230. A registered dietician at the home said she was not alerted to the decline in the resident’s fluid and meal intake, the citation said. The citation also said the home’s records failed to show that the resident’s hydration had been assessed.

Michael Landi, chief operating officer of iCare Management, which owns Touchpoints, issued the following statement: “Our facility strives for all residents to reach their highest level of health, independence and well-being. While we disagree with the findings by [DPH], the facility has implemented appropriate interventions which have been accepted by the department, and we are currently in full compliance with regulatory standards.”

On Aug. 11, DPH fined another iCare home, Westside Care Center in Manchester, $1,090 in connection with the verbal and physical abuse of a resident in April 2015.

The citation said a nurse’s aide yelled at a resident and dragged the person down the hall by the collar.

The fine was also imposed in connection with a resident who sustained a bruise on the face and shoulder, possibly from a fall, in May 2015.

The resident had a history of transferring back to bed without waiting for help and had done so on May 24, when nurses noticed the bruises and suspected that the resident had fallen. Despite that suspicion, the home did not do a neurological assessment of the resident and did not monitor the resident, the DPH citation said.

The resident was hospitalized, and the staff was retrained on how to handle neurological assessments and injuries of unknown origin, the citation said.

“The events in question were isolated in nature and not representative of the high standards of care and service we expect from each employee,’’ Landi said. “As with any other similar situation, the facility provided education and subsequent monitoring through its comprehensive quality assurance and performance improvement system.”

Orange Health Care Center was fined twice, for a total of $2,600, on Aug. 6 in connection with a resident who was hospitalized with gastro-intestinal bleeding in April 2015.

The first citation, which carried a fine of $1,510, states that the home’s records failed to show that the resident’s stools had been tested for blood as had been ordered.

The second citation, which includes a fine of $1,090, states that an advanced practice registered nurse was not informed that the same resident had a tarry stool and a vaginal discharge. Had she been notified, she said she would have ordered more tests and consulted a doctor, the citation said.

Administrator Ellen Casey said that the DPH made the home aware of the deficiencies and that a correction plan had been developed and approved by the state.

“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,” she said.

On Oct. 30, Governor’s House Rehabilitation & Nursing Center in Simsbury was fined $1,020 in connection with a resident with Type II diabetes who was hospitalized on Oct. 15 with hypoglycemia after an error involving the resident’s insulin, the DPH citation said.

In response to the incident, the home retrained its staff on administering insulin and conducted an audit on all residents receiving insulin. The home has not had any other errors involving insulin, the citation said.

Jeanne Moore, a spokeswoman for Genesis Health Care, which owns Governor’s House, said the home worked with DPH and “very quickly regained regulatory compliance. Governor’s House is committed to providing quality care to its patients and residents.”

On April 20, Jerome Home in New Britain was fined $1,600 in connection with a resident who fell out of a wheelchair and sustained a cut on the forehead on Oct. 6.

The citation said a nurse’s aide was pushing the resident with laundry in one hand and was later counseled not to carry laundry while transporting residents.

Executive Director Lori Toombs said the home took the issue seriously and is conducting audits to ensure the staff follows the proper protocol when transporting residents. “As a result of a recent issue at Jerome Home, involving a patient fall, we have implemented additional training for staff when conducting patient transports,’’ she said. “Patient safety will always remain at the forefront in providing the highest quality of care to our patients every day.”

On Oct. 28, Westport Rehabilitation Complex was fined $650 in connection with the care of three residents with pressure sores in 2015.

The home was also cited in connection with a resident who fell out of a wheelchair and broke a leg bone while a nurse’s aide was trying to move the person into a lift, the citation said. In response to the incident, two staff members are now required when placing a sling-type lift under residents, the citation said.

The home’s executive director could not be reached for comment.

2 thoughts on “Six Nursing Homes Fined Following Resident’s Death, Lapses In Care

  1. As an RN and CNA instructor I see the many issues in nursing homes. Poor reimbursement leading to extremely depleted resources is huge. While some staff may not be very good I see a lot of hard working caring people in nursing homes.

    • Jessica, Although I agree with your point that poor reimbursement and depleted resources is a problem. There is absolutely no excuse for a CNA, RN, LPN, or anyone else, to abuse a patient. I worked in nursing homes for many many years and I understand how of a job this is. But these patients, most of them alone, with no family members around, living out the rest of their life deserve respect and care that each and every one of us would want for our own family member.

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