State Fines Six Nursing Homes Following Residents’ Deaths, Care Lapses

Print More

Six nursing homes have been fined for violations, including two incidents where residents died.

The Reservoir in West Hartford was fined $3,000 after a resident died and investigators found staff did not administer CPR for the required period of time, according to the state Department of Public Health (DPH).

The resident, who was at the facility for short-term rehabilitation, had difficulty breathing on Feb. 6, 2016. A licensed practical nurse (LPN) began performing CPR compressions but soon after, a registered nurse told the LPN to stop the compressions, according to DPH.

Policy states staff must perform CPR until emergency personnel arrive, according to the DPH citation. When emergency personnel arrived, they administered CPR and took the resident to a hospital but the resident was dead on arrival.

“We have provided additional education to our staff and are in full compliance,” said spokeswoman Jeanne Moore. “The Reservoir is committed to providing quality care to its patients and residents.”

Advanced Center for Nursing and Rehabilitation in New Haven was fined $3,000 after a resident with acute kidney injury and other diagnoses died. The citation said the resident’s blood had a critically high level of sodium.

A physician’s order said the resident was to take in between 2,000 and 2,400 cubic centimeters of fluids daily, according to DPH, but records from Feb. 10 to Feb. 20, 2017, lacked entries for 11 out of 30 shifts.

According to the citation, one nurse noted the resident’s poor fluid intake but did not notify supervisors, and another nurse failed to assess the resident. After developing a fever and becoming lethargic, the resident was taken to a hospital Feb. 20 and died there six days later.

Officials at the facility did not return a call seeking comment.

RegalCare of West Haven was fined $1,930 for three incidents.

A resident had a pressure wound on the lower back on Nov. 10, 2016, according to DPH, but a doctor’s order to treat it was not written until Nov. 14 and documentation indicated the wound wasn’t treated until Nov. 16.

Another resident, who was being administered oxygen, was injured behind the left ear Dec. 1, 2016. According to DPH, staff did not put protective ear guards on the resident’s oxygen tank, as is protocol and they misclassified the injury as an abrasion when it was a pressure wound.

Staff kept incomplete records on another, anorexic resident at risk for dehydration, the citation said. The resident was supposed to consume 1,669 cubic centimeters of fluids daily, but documentation for several days between Dec. 6 and Dec. 11, 2016, was incomplete. According to DPH, the resident had an elevated white blood cell count on Dec. 12 and needed intravenous fluids.

Officials at the facility did not return a call seeking comment.

Salmon Brook Center in Glastonbury was fined $1,740 after a resident broke several ribs in a fall. Two nurses’ aides were moving the resident with a mechanical lift on Jan. 27, 2017, when a sling near the resident’s right leg came undone, according to DPH.

The resident was treated at a hospital for multiple broken ribs and excess fluid around the lungs. The aides were given written warnings.

Officials at the facility did not return a call seeking comment.

The Villa at Stamford was fined $1,630 for two incidents.

On Sept. 21, 2016, a housekeeper saw a nurse’s aide hit, push, pull and yell at a resident with dementia while shaving the resident in bed, according to DPH. The aide denied the allegations and was fired six days later.

On Dec. 2, 2016, a resident suffered lacerations to the side of the head and behind one ear after a nurse’s aide tried to turn the resident over while providing incontinence care. The resident, who had Parkinson’s disease and traumatic brain injury, required two-person assistance, according to DPH, but the nurse’s aide tried to move the resident without help. The resident was treated at a hospital and returned to the facility three days later.

Officials at the facility did not return a call seeking comment.

Bayview Health Care in Waterford was fined $1,630 for two violations.

In early 2016, a quadriplegic resident fell on three separate occasions while being repositioned in bed by nurses’ aides. After the first fall, on Feb. 14, the resident’s care plan was updated to require two-person assistance for repositioning, but the resident fell again on March 15 and March 19 when a lone nurse’s aide tried to move the resident.

Another resident suffered a skin tear on the upper shin while being moved on Nov. 21, 2016. According to DPH, the resident’s care plan was updated to require the use of shin tubes on both legs during all transfers, but the resident suffered a 3-inch calf laceration Feb. 16, 2017, when a nurse’s aide failed to use the shin tubes.