Five Connecticut nursing homes have been fined by the state Department of Public Health (DPH) for various violations, including several instances in which equipment wasn’t properly cleaned.
In one citation, Apple Rehab Saybrook was fined $10,000 for two violations.
On Sept. 4, 2018, two licensed practical nurses (LPNs) failed to properly clean and sterilize glucometers after drawing blood from multiple diabetic residents. One LPN who took blood from two residents and another who drew blood from four residents cleaned glucometers with alcohol wipes instead of germicidal wipes, the citation said.
The first LPN said she didn’t know germicidal wipes were necessary, while the second LPN said she was “somewhat aware” of the need to use them but didn’t know where they were stored, the citation said.
On Jan. 13, 2018, a resident with osteoporosis suffered femur and pelvic fractures after being moved by two nurse aides from a wheelchair to a bed. The nurse aides used a sliding board to move the resident, according to the citation, but staff weren’t positioned correctly and failed to use a gait belt. Following each incident, staff were educated about policies and protocols.
In a separate citation, Apple Rehab Saybrook was fined $1,480 after an LPN threatened a resident who had Alzheimer’s disease and anxiety. On Oct. 19, 2017, the LPN was walking the resident back to the resident’s room when the resident put a hand in the LPN’s face. The LPN said “if you slap me you will end up in the hospital,” according to the DPH citation. The LPN was suspended and later terminated.
The Suffield House was fined $6,000 for instances in which staff failed to properly clean glucometers.
On Sept. 20, 2018, three LPNs tested multiple residents’ blood sugar with glucometers and cleaned the equipment with alcohol-based wipes that did not contain a disinfectant, DPH said. The facility implemented a quality assurance program and twice weekly monitoring by the director of nursing services to ensure compliance, according to DPH.
“Suffield House always strives to practice the highest standards of infection control. Although we did sanitize the glucometers, we did not do so to the manufacturer’s requirements, which we immediately rectified,” Celia Moffie, managing member, said.
Laurel Ridge Health Care Center in Ridgefield was fined $6,000 after a resident with Multiple Sclerosis choked while being fed a hamburger by a nurse aide.
The resident, who was at risk for aspiration and on a special diet, choked during dinner August 11, 2018, and required the Heimlich maneuver to clear the airway. According to the citation, the nurse aide who helped the resident eat knew the resident wasn’t supposed to have hamburger but fed a bite to the resident anyway because it was on the food tray. A cook later said he served the meal based on what a dietary aide called in and didn’t look at the resident’s meal ticket.
The nurse aide didn’t report the mistake to the charge nurse or offer the resident an alternative meal, according to DPH. Following the incident, all staff involved in meal service were re-educated about aspiration precaution, and audits were implemented to ensure accuracy of meal tickets and trays, according to DPH.
Northbridge Health Care Center in Bridgeport was fined $3,060 for an incident in which a resident suffered bleeding in the brain after falling while being transferred by two staff from a shower chair to a bed.
An LPN and nurse aide were moving the resident with a Hoyer lift on July 30, 2018, when the resident fell to the floor and suffered a head injury, requiring admittance to a hospital, according to the citation. An investigation found the lift’s legs weren’t fully functioning and didn’t open, and the resident lift pad was attached to only five of six loop attachments.
“Northbridge Health Care Center takes the care of its patients and residents very seriously and has a zero-tolerance policy regarding employees following or not following standards of care,” spokesman Tim Brown said. “We are confident that the issue raised in the report was isolated and not consistent with the care and customer service at our center. While the employees involved in this incident were terminated for their actions, Northbridge Health Care has retrained our care team on policies, procedures and expectations for our care to ensure such an incident does not occur again.”
Park Place Health Center in Hartford was fined $1 after an LPN incorrectly cleaned a glucometer on Aug. 13, 2018. According to the citation, the LPN cleaned the device with an alcohol wipe after using it on a resident, and reported having done the same after using it on three other residents previously. The LPN didn’t know disinfectant wipes should have been used.
Following the incident, the facility re-educated and conducted competency reviews of all licensed nursing staff on blood glucose monitoring techniques, according to DPH. The fine was $1 because the facility is in receivership, according to Christopher Stan, DPH spokesman.
Officials at Apple Rehab Saybrook, Laurel Ridge and Park Place did not return phone calls seeking a comment.