Eight Nursing Homes Fined, Following One Death, Care Lapses

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Eight Connecticut nursing homes have been fined by the state Department of Public Health in connection with one resident’s death and other incidents of rapid weight gain, cuts and broken bones among residents.

On Nov. 7, Beacon Brook Health Center in Naugatuck was fined $2,180 in connection with a resident who died May 23 of cardiopulmonary arrest and a bowel obstruction, DPH records show. DPH found that the home’s medical records failed to reflect that an abdominal assessment was done on May 23 after the resident complained of nausea and a stomachache on May 22.

Also, medical records did not indicate that a physician had seen the resident after May 21, and the home did not have a policy about abdominal assessments, DPH records show. On May 23, the resident was found without a pulse and CPR was started. The resident died after paramedics arrived and took over the CPR, records show.

In an unrelated case, a Beacon Brook resident with congestive heart failure mistakenly was not given medication for fluid retention, and no weight gain parameters were noted in the resident’s record that would have triggered a doctor’s notification, records show. The resident gained nine pounds between July 10 and July 21 and was hospitalized for shortness of breath and fluid overload. DPH found that the drug was noted in a physician’s order but not in the medication record, so the nursing home stopped giving it to the resident on July 9. The resident spent five days in the hospital, records show.

Beacon Brook’s administrator, Linda Garcia, said that the incidents happened before she took over, so she could not comment.

On Nov. 6, Manchester Manor Health Care Center was fined $2,250 in connection with two incidents, including one on May 29, when a nurse’s aide had left a resident in a bathroom, heard a thump and then found the resident on his or her knees with a deep cut on the forehead. The cut required five stitches to close, and inspectors found that the aide had violated a safety rule at the home by leaving the resident alone, records show.

A nurse was observed on Oct. 30 giving a resident with Alzheimer’s disease coffee without a lid in violation of a doctor’s order that the resident be given a lid on all hot drinks. State records show the resident had been burned on the thighs Aug. 2 and on the abdomen on Oct. 2 after spilling hot coffee that was provided without a lid.

Administrator Mary Ellen Gaudette said the staff has been retrained since the incidents and the home is in full compliance with state regulations.

On March 4, Ingraham Manor in Bristol was fined $1,595 in connection with the care of two residents. On Nov. 6, 2012, a psychiatrist at the home recommended that a resident with bulimia who was observed with fingers down his or her throat be admitted to a psychiatric hospital. The behavior continued, but the home was told no beds were available at a psychiatric facility. Fourteen days later, the resident was found to be lethargic and was hospitalized with elevated potassium and low salt levels in the blood. DPH found that the home should have notified the psychiatrist that the behavior was continuing and that the resident had not been hospitalized.

On April 19, 2012, a resident who was hard of hearing fell backward and hit his or her head when a nurse’s aide had moved a shower chair. The resident did not hear the aide say “wait.” The resident was not injured, but the fall prompted the home to direct the staff to keep the person’s walker within reach.

On May 17, 2012, the same resident fell backwards after a shower when the aide had removed a shower chair and told the resident not to sit back, records show. The resident was sent to a hospital and was found to have a pelvic fracture. The home found that the nurse’s aide should have kept a hand on the resident while moving the chair after the shower, records show.

Administrator Linda A. Urbanski said in a written statement that the home cannot comment on specific cases but added “we apologize for these unfortunate incidents.”

“Ingraham Manor continues to maintain a culture of safety, quality and service…,’’ she said. “Additionally, Ingraham Manor carefully reviews best practices and provides educational sessions on a continuing basis to ensure that safe and high quality care is provided to all patients and residents.”

On Oct. 23, Silver Springs Care Center in Meriden was fined $1,440 in connection with a private contractor hitting a resident. The resident said that on Sept. 7, he was trying to retrieve cans from the trash when the contractor started pushing him. The resident said he spit in the person’s face and called him a racial slur and the contractor then hit him three times with a sign, records show. The resident was bruised on the neck and shoulder and scratched on the arm, records show.

The worker was fired, records show. The police were notified about the incident, but it was unclear whether an arrest was made.

Administrator Patrick McDonnell confirmed the incident happened with a contractor but privacy laws prevent him from providing details. “Although this matter did not involve any of our employees, we take all allegations very seriously,’’ McDonnell said in a written statement. “In this case, we promptly notified state and local authorities, and we took immediate action to address the situation.  We continue to be committed to the highest possible level of care and safety for our residents.”

On Oct. 30, the Woodlake At Tolland nursing home was fined $1,300 in connection with a resident with pneumonia who developed a fever and was lethargic. Records show the resident’s fluid intake goals were not noted in the resident’s care plan on June 11, or on June 15. On June 14, the resident had a fever of 101.2 degrees. The director of nursing said staff members should have looked up the fluid needs of a resident that a dietician had calculated, records show.

Eric C. Berthel, a spokesman for ECHN, which owns Woodlake, declined to comment, citing federal privacy regulations and company policy.

On Sept. 26, Hamden Health Care Center was fined $1,020 in connection with a resident who broke a leg in two places. The person’s care plan called for two people to move him or her from a walker or wheelchair, but on Jan. 6, a nurse’s aide moved the resident from a toilet to a wheelchair alone. The person’s knees buckled, resulting in him or her being “lowered to the floor,” records show. The resident was found to have broken two leg bones, records show. The nurse’s aide admitted to not thoroughly reviewing the care plan before moving the resident, records show.

On Nov. 21, Regency Heights of Windham was fined $500 in connection with the case of a resident with a terminal diagnosis who tried to commit suicide three times. Records show that the resident was found with a pillow over his or her face and said he or she wanted to die. The resident was sent to a local hospital for observation and returned to Regency Heights on Oct. 5. The next day, the resident was hospitalized again after threatening to commit suicide.

Back at Regency on Oct. 16, the resident was found with a bell cord wrapped around the neck and was hospitalized and returned to the nursing home that night. On Oct. 17, the resident was found with a pad from a bedrail bumper held against his or her face and was readmitted to the hospital. Under the nursing home’s policies, the resident should not have been left alone after the first suicide attempt and dangerous objects should have been removed from the room. The director of nursing said he or she was not aware of the Oct. 4 suicide attempt and could not tell state investigators whether the room was deemed safe after the Oct. 4 and 6 incidents, DPH records show.

On Nov. 21, Sharon Health Care Center was fined $360 in connection with the improper use of a belt to restrain a resident in a wheelchair on Oct. 26. A physical therapist found the resident restrained to a wheelchair with a belt even though no restraint use had been ordered by the resident’s doctor, DPH records show.

Officials at Hamden Health, Regency and Sharon Health could not be reached for comment.


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