Five Connecticut nursing homes received fines of more $1,000 each from the state Department of Public Health in connection with lapses of residents’ care, including cases that led to broken bones.
Details of the cases were outlined in citations released Friday by DPH.
On Jan. 27, Woodlake at Tolland Rehabilitation and Nursing Center was fined $1,580 in connection with lapses in the care of three residents, DPH records show.
In October, the nursing staff failed to give a resident with congestive heart failure a diuretic for 14 days, records show. Officials said it was due to a glitch in a computer system and that this was the only resident whose treatment was affected by the problem.
In November, a resident with heart disease was ordered on an extended release form of a drug, but a short-acting form of the drug was mistakenly given, DPH records show.
For three days in November, the home also failed to change a resident to a soft diet despite an order to do so from a speech therapist, records show. The resident was hospitalized with pneumonia.
A spokesman for ECHN Eldercare Services, which owns Woodlake, could not be reached for comment Friday.
Last July, Aurora Senior Living of New Britain was fined $1,580 in connection with lapses of care involving five residents. On April 28, a nurse’s aide had lowered the side rail on the bed of a resident with dementia and turned to get an item from a closet. During that time, the resident rolled off the bed and suffered a broken nose, records show. The aide was retrained in how to provide safe care, records show.
On May 15, a resident with dementia had placed a pillow and blanket on the face of a resident with Alzheimer’s disease and told a nurse’s aide that he or she was trying to quiet the “dog” in the room, records show. The second resident had reddened areas and trauma on the face. The first resident was sent to an acute care hospital, where it was determined he or she was not a threat to others and was returned to Aurora, records show.
An investigation determined that a nurse’s aide should not have left the first resident unattended when seeking help during the incident, records show. Records show the home retrained the aide and all other staff members on how to handle an assaultive resident.
In another incident at Aurora cited by DPH officials, a resident was missing from the home for an hour and a half on June 28 until found in the nearby woods by police using a tracking dog.
Records indicate that a charge nurse had searched the building, and then ordered a wider search 30 minutes after the resident was first reported missing. Police were called 38 minutes after the initial report, records show. A review of the home’s policies indicate that when a resident cannot be found in a unit, a wider search should be ordered and a page should be repeated three times.
On July 2, numerous medications were observed unattended on top of a medication cart while a nurse had gone to answer a phone and a resident was near the cart, records show. The nurse received training on the proper care of medication.
In a July 6 incident, a resident with hepatitis C and depression turned off an alarm and left the home alone, records show. The resident was found down the street. An investigation concluded that the resident’s care plan did not indicate a history of turning off the alarm and that records failed to list that the resident was being given anti-depressant and anti-psychotic drugs.
The Portland Care and Rehabilitation Center was fined $1,440 on Oct. 29 in connection with lapses in care of three residents.
On June 2, a resident with depression and dementia fell off a raised toilet seat to the floor and was found to have a non-displaced hip fracture, DPH records show. An investigation found that the raised seat may not have been placed properly on the toilet, records show. The nurse’s aide who had been assisting the resident was retrained, records show.
On Sept. 24, a resident was admitted to a hospital with for a pelvic fracture. The resident said his or her legs had been twisted during a transfer from a toilet to a wheelchair by two aides. The aides were fired, records show.
Also in September, the home failed to properly track the stages of a resident’s pressure ulcer, records show.
The Middlesex Health Care Center was fined $1,230 on Jan. 27 in connection with a March 28 incident in which a resident with dementia hit his or her head on a nightstand and suffered a cut that required four staples to close, records show.
A nurse’s aide admitted that he transferred the resident to a bed without using a mechanical lift or the assistance of another staff member, records show. The home’s administrator said Friday that he could not comment on the fine.
Aurora Senior Living of East Hartford was fined $1,020 on Sept. 17 in connection with an incident in which a resident suffered two broken leg bones, records show.
The resident, who was obese and had dementia, was being helped to use a toilet when he or she became weak and was lowered to the knees and then to a sitting position by aides.
The aides said that they had not evaluated the space available in the bathroom or the need for supportive equipment, records show. The home reported that it then re-trained staff members on how to safely transfer residents safely and how to identify risk factors for falls and fractures, records show.
Officials from the two Aurora homes and Portland Care could not be reached for comment Friday.
Thank you Kate Parrish for such a thorough account. Also most residents and their families do not report incidents to the DPH for a few reasons and those that do find a long wait time for a response. The fines are more if a dog bites you than a person who has a life threatening pressure sore, bone break, or gets tangles in a wire or chokes. Training of health care assistants, certified nurses aides and LPN’s are minimal. When my mom was at a skilled nursing facility on the Shoreline a newly hired aide that was in orientation came in answering a call button. It was her first day and she apologized explaining that it was her first day and someone was suppose to be with her during her orientation process. We got though it and I was glad to finally get an honest answer. A few months later, she was the one orientating other new aides. I don’t see how good her orientation was since she didn’t have any. But the constant turnover of staff with the constant use of pool staff floaters instead of steady staff added to the care concerns raised at Family Council meetings which were independently held. I am sure if you look further you will find that any “retraining” was a couple of sentences. Excuses like “that person is no longer here” is a convenient way out of answering questions. The surveyor reports are usually out for people to read but no one knows that they are. I found the one at Madison House stuffed in a drawer in their lobby. You should read The Grimes Center surveyor report which used to be affiliated with St. Raphael’s and is now part of Yale. This is Yale’s first attempt at caring for nursing home residents and the board members who are in charge of The Grimes Center are unavailable for questions regarding care from some of the families. Then there’s Apple Rehab in Old Saybrook who cleared out one of its 30 bed units to rent it out to either the VA or a hospice company. All of the residents were displaced into rooms in an older portion of the building with no regard for roommate placement. It also willfully interfered preventing the Family Council from meeting on a regular basis. Keep up the good work and if you are seeking any help from me, just ask. Thank you again Kate.