August 3, 2016

Three Nursing Homes Fined Following Falls, Medication Error

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Three nursing homes have been fined more than $1,500 each by the state Department of Public Health in connection with residents who fell, broke bones or received the wrong medication.

On June 21, Pilgrim Manor of Cromwell was fined $1,930 in connection with three residents who were hospitalized with injuries.

One resident suffered a broken hip while being moved that required hospitalization on Dec. 28, DPH’s citation said.

The state found that the home failed to complete a thorough assessment when the resident complained of pain and could not bear weight on a leg. The home also failed to intervene in a timely fashion and waited 16 hours before noting a change in the resident’s condition. The resident was then sent to the hospital, the citation said.

The home was also cited in connection with another resident who fell on Oct. 4, 2015 and was bleeding from the nose. An alarm was supposed to be used on the resident’s bed and chair, but no alarm was sounding when the resident was found on the floor, the citation said. The state concluded that the home failed to ensure the resident’s safety, the citation said.

DPH drew the same conclusion in the case of a resident found sitting on the floor May 26 and bleeding from the back of the head, the citation said. DPH found that a nurse’s aide should not have left the resident unattended, the citation said.

Pilgrim Manor’s Healthcare Administrator Maria Minkos said through a spokesman that DPH has accepted the home’s plan of correction and that the home is in full compliance with state standards following a re-inspection on July 28.

“Pilgrim Manor has always been mindful of the responsibility it has for ensuring our chronically ill residents receive the best in attentive and compassionate nursing assistance,’’ she said. “We have redoubled our efforts to provide the proper staff, support and training.”

On June 27, The Summit at Plantsville in Southington was fined $1,840 in connection with the care of two residents.

DPH’s citation said the home waited six hours on July 19, 2015 to send a resident with declining vital signs to a hospital. The person was admitted to intensive care with sepsis, high blood sugar and pneumonia, the citation said. The home’s medical director told state officials that the person should have been sent to the hospital immediately, the citation said.

The home was also cited for a medication error on June 26, 2015 when a licensed practical nurse gave a chemotherapy drug used to treat leukemia to the wrong resident, the citation said. The nurse noticed the error immediately and reported it, and the resident was monitored and found to have no ill effects from the mistake, the citation said. The nurse was re-trained in how to administer medication, the citation said.

Administrator John Kelly could not be reached for comment.

On June 30, the Woodlake at Tolland Rehabilitation & Nursing Center was fined $1,540 in connection with a resident who fell Dec. 20 after going to the bathroom without asking for help. No injuries were found that day, but three days later, the resident complained of groin and hip pain. X-rays showed the resident had fractured a bone in the pelvis, DPH’s citation said.

The resident was urged to call for assistance before getting up. The state concluded that the home’s plan of care failed to reflect that staff members intervened when the resident moved from a bed to a chair without asking for help four more times, the citation said.

On Jan. 31, the resident fell again and was found to have broken a collarbone, an elbow and a hip, the citation said. The resident required surgery to repair the elbow and received a transfusion because of “acute blood loss due to the fractures,” the citation said.

Nina Kruse, a spokeswoman for Eastern Connecticut Health Network, which owns Woodlake, said that DPH “has assessed the practices at Woodlake at Tolland and we are in full compliance. We are currently conducting an internal audit on how to improve interventions and have implemented changes to ensure [that] the highest level staff training and quality care is provided.”

One thought on “Three Nursing Homes Fined Following Falls, Medication Error

  1. No surprise people get out of bed on their own as they get tired of waiting for assistance. Nursing homes need more staff. If you care about the patients, hire more staff. It’s only going to get worse as our generation gets older. Sad that fines have to be imposed before something gets done.

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