Medication Errors, Falls Result In Nursing Home Fines

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Seven nursing homes have been fined by the state Department of Public Health in connection with medication errors or residents who fell or sustained broken bones.

On Feb. 5, two fines totaling $2,740 were imposed on the Golden Hill Health Care Center in Milford in connection with an incident July 31 in which a resident broke a leg.

The resident was diagnosed with a broken leg and bruises on Aug. 1, DPH records show. The state found that the home had failed to notify a physician for eight hours after the staff noticed the resident moaning and crying.

The home was also cited in connection with the same incident when DPH found that a nurse’s note failed to document that the resident was assessed after showing signs of pain. Records also showed that the resident was not sent to a hospital emergency room until more than 10 hours after he or she had signs of unrelieved pain, DPH concluded.

Two nurse’s aides were disciplined in connection with the incident, including one aide who made a false statement about the way he or she transferred and showered the resident, records show.

Ben Atkins, chairman of Traditions Senior Management of Clearwater, Florida, said his firm began managing Golden Hill in January for the non-profit Eagle Lake Foundation, which is taking over the home. He pointed out that the citations refer to deficiencies that happened at Golden Hill before his company was involved.

“We’ve very serious about the care we provide,’’ he said.

On Feb. 26, Regency Heights of Stamford was fined $1,370 for several incidents, including one in which a nurse’s aide punched a resident, DPH records show.

On April 16, the resident struck the aide first, and the aide punched the person in the arm, records show. The resident was not injured. A doctor and local police were called and the aide was removed from the unit. A witness said the aide could have just walked away. The aide reported that the resident had “done this to me before and I deserve respect,” DPH’s citation states.

The home was also cited in connection with a May 12 incident in which a resident suffered a broken toe when a shower door inadvertently closed on the resident’s foot, DPH records show. The home found a nurse’s aide should have gotten help in holding the door open, and the aide was given a written warning and re-training, record show.

Regency Heights was also cited in connection with an incident Oct. 20 when a resident fell out of a lift sling and hit his or her head while being moved from a bed to a wheelchair, records show. The resident was hospitalized for three days for a hematoma.

The state found that the aide had failed to check the straps on the lift before moving the resident out of bed, records show. Two aides were provided with additional training because of the incident, records show.

On Jan. 5, 2014, a Regency Heights resident was observed with a large bruise on the face. It was determined that the resident had been moving him or herself in a wheelchair and was not wearing non-skid socks when he or she should have been, records show. A nurse’s aide reported that he or she did not know the resident required non-skid socks, records show.

A DPH found that the resident had fallen four times in 2014 – on July 14, Aug. 10, Sept. 21 and Dec. 21 – and that the home did not revise its care plan after the August and December falls.

Regency Heights was also cited in connection with an incident on Dec. 14, 2014, in which a resident broke a bone in the hand, records show. DPH found that two aides had transferred the resident out of bed using a lift without the consent of a licensed staff member, records show.

The home was also cited in connection with a resident with diabetes who was hospitalized after not being given three doses of a required drug, DPH found. The hospital reported the incident to the state because a doctor felt it would not be safe to return the resident to Regency Heights, DPH records show. Three nurses reported that they could not find the drug, did not call a doctor and did not notify a supervisor, DPH found. One nurse was fired and two were given written warnings, DPH records show.

Administrator Grace Flight said the home is in full compliance with state regulations and “everything has been corrected that was cited.’’

On Jan. 22, Montowese Health and Rehabilitation Center was fined $1,230 in connection with a July 1 incident in which one resident was hospitalized after taking another resident’s medication, DPH records show.

A registered nurse reported going into a room with medication for both residents when he or she heard one of the residents cry out from the bathroom and appeared to be about to fall, records show. The nurse put both residents’ medicine on a table in front of one resident’s bed while helping the other. The nurse found that the resident in bed had taken some of the other resident’s drugs by mistake, records show.

DPH found that the nurse violated the home’s policy, which states that medications should never be left unattended.

“The facility is now back in substantial compliance with federal and state standards of medication practice protocol,’’ Genine Tannoia, director of nursing services at Montowese, said.

On Feb. 5, Masonicare Health Center of Wallingford was fined $1,160 in connection with a resident who fell on April 24 and broke an arm when an aide was transferring the resident from the bed to a wheelchair, records show. The aide admitted that before moving the resident, she had not checked the care plan, which required that two aides move the person using a lift, records show.

Masonicare spokeswoman Margaret Steeves said an investigation was conducted, which led to the firing of the employee involved in the incident.

On Feb. 6, The Reservoir of West Hartford was fined $1,020 in connection with a resident who was given a medication used to treat heart failure for three days in May even though a doctor had ordered it discontinued, DPH records show. The resident was treated at a hospital for toxicity involving the drug Digoxin, records show.

In response to the incident, the licensed nurses were retrained and audits were conducted of all residents on Digoxin, records show. The Reservoir’s administrator declined to comment.

On Feb. 23, Crossings East Health and Rehabilitation Center of New London was fined $1,020 in connection with a resident who developed a pressure sore on Jan. 3 of this year. DPH found that the resident’s care plan lacked documentation that the home had consistently monitored the resident’s skin.

Stacey Brady, a spokeswoman for Crossings East, said the home quickly submitted a correction plan to DPH after the incident and is waiting for word that the plan has been accepted.

“We are committed to providing our patients with the utmost of care,’’ she said.

On Feb. 17, Talmadge Park Health Care of East Haven was fined $420 in connection with a resident who began choking on a piece of sandwich Dec. 11. The resident, who has depression and bipolar disorder, said he or she had tried to choke as a way to commit suicide, records show.

A physician reported that he or she was not informed that it was a suicide attempt until the next day, records show. The resident was hospitalized that day, records show.

Talmadge Park Administrator Ted Vinci said the home’s staff quickly performed the Heimlich maneuver and prevented the resident from choking. He conceded there was unclear communication when the incident was reported to a physician.

“This was an isolated issue and although no disciplinary action was warranted, we have provided additional training for the staff regarding improved communication to physicians,’’ he said.




2 thoughts on “Medication Errors, Falls Result In Nursing Home Fines

  1. My Mom Anna Figuly age 91 has been a resident of Golden Hill Milford Ct 06460 for almost 4 yes. She is mobile and needs limited care but needs care. On Saturday June 24 2017 she was discovered on the floor around 3:30pm My sister left at 2:00 after a 2 hr visit When she was found she complained of pain on her right side and difficulty breathing the so called head nurce Paula told my brother she checked her out and felt she was just shaken and sore BUT if he wanted she could have the X-ray tech come in that would b about a 4 hr wait my brother insisted they call 911 and she was brought to Milford Hos she had a broken right hip and 2 very bruised ribs surgery was don Sunday am That staff knows my mom she has taken falls before but never said she was in pain BUT this time she did The nurce decided she would make her decision and risked my Mothers life Elderly Abuse is not acceptable The administer Ted Vinci has not returned my calls and the woman Paula needs to realize she was wrong. I am requesting this be investigated. Luckily my mom is recovering in Milford Hos and will do rebab at Golden Hill one thing I will say their rehab people are great but the lack of compassion by the staff is terrible My mom fell because she was trying to help a room mate that was calling for help for over 30 minutes so if the staff was doing their job thus never would have happened and by the way that Paula said they were busy changing shifts. I expect to hear from you after you investigate this painful matter . Patricia Riegert. 203 804 0558

  2. I want the name of a local Elderly abuse Attorney to look into my moms accident at Golden Hill rest home 2028 Bridgeport Ave Milford Ct 06460