Nursing Homes Cited After Resident’s Suicide, Lapses In Care

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Five nursing homes have been fined at least $1,000 by the state Department of Public Health (DPH) in connection with lapses in care, abuse of one resident and a resident who committed suicide.

The largest fine—$3,000—was levied on Cheshire Regional Rehab Center in connection with four residents who said they faced delays in receiving incontinent care. In one case, in October, a resident was placed in a wheelchair and was not changed for 10½ and hours, when incontinent care is supposed to be provided every two to three hours, the citation said.

Ben Atkins, chairman of the home’s parent company, Traditions Senior Management of Clearwater, Fla., disagreed with the length of the waits, but added, “People shouldn’t have to wait.”

The citation also involved a resident who complained in October about being left in a shower for nearly an hour. The resident banged on pipes to call for help because an emergency call system was not within reach, DPH’s citation said. Atkins said this resident was able to shower independently, so the home immediately added a call button that the person could reach.

The home was also cited in connection with a resident who was ordered an antibiotic for a sinus infection even though records showed an allergy to a similar antibiotic, the citation said. The order for the drug was discontinued when a pharmacy noticed the problem. A registered nurse did not recall reviewing the resident’s allergies before the antibiotic was ordered, the citation said.

Atkins said the nurse was a temporary employee who no longer works at the home.

“We have recently hired all permanent staff and that should make a big difference’’ in operations there, he said.

On Jan. 12, Mystic Healthcare & Rehabilitation Center was fined $1,020 in connection with a resident who committed suicide by asphyxiation with a plastic bag in bed on Dec. 21, the DPH citation said.

DPH found that the resident’s care plan did not include the person’s history of suicidal thoughts, and notes from a psychiatric visit failed to say that the resident had previously been hospitalized for suicidal ideation.

A licensed practical nurse and a nurse’s aide said the person had not exhibited any actions that would indicate suicide was a possibility, but they acknowledged they were unaware of that part of the resident’s history, DPH found.

Stella Akopyants, corporate clinical director for Ryders Health Management, which owns the Mystic home, said state and federal privacy laws prohibit her from providing any more information.

“The health, safety and well-being of our residents is our top priority at Mystic Healthcare, and we continue to be committed to delivering the best care possible to our residents,’’ she said.

On June 22, 2015, Autumn Lake Health Care at Cromwell was fined $1,090 in connection with medication errors involving two residents. In March, a resident who was supposed to be given a blood thinner did not receive it for 11 days, DPH said.

On April 22, a resident was hospitalized for a grand mal seizure. DPH’s citation said the resident had not been given anti-convulsive medication for two days because a registered nurse supervisor had failed to list the medication in the nursing home’s computer system. The nurse was fired.

Autumn Lake’s administrator, Jessica Garcia, declined to comment directly on the citation but said, “Autumn Lake Health Care at Cromwell remains committed to providing quality care for our patients and residents.”

Meadowbrook of Granby was cited twice on Jan. 21 and ordered to pay fines of $1,510 and $1,440.

The higher fine was assessed in connection with a nurse’s aide who spoke to a resident inappropriately and held the person’s hands down, the citation said. The recreation director witnessed the incident and considered it abuse while the aide said she was trying to defend herself from an aggressive resident, the citation said. The aide was fired.

That citation also involved a resident whom the home failed to assess for dehydration, the citation said.

In the case of the $1,440 fine, the citation said the same resident was hospitalized April 17 for being lethargic and moaning. A review of the resident’s care found the fluid intake was too low on nine of 13 days, and a nurse’s note failed to reflect that a doctor had been notified when the resident showed symptoms of a urinary infection, DPH’s citation said.

The home’s administrator did not return calls seeking comment.

On July 30, Portland Care & Rehabilitation Center was fined $1,020 in connection with a resident who developed a deep tissue injury on a heel in July, DPH’s citation states. The home’s records failed to document that the resident’s heels were “off-loaded,” or elevated, for six days, the DPH citation said.

The home’s administrator did not return a call seeking comment.


6 thoughts on “Nursing Homes Cited After Resident’s Suicide, Lapses In Care

  1. My family member was at mystic rehab paralyzed In a wheelchair left alone in a dark room for hours unable to move he wheelchair. Abused, mistreated and neglected. My faith in humanity has been completely lost after this disheartening experience.

  2. My mother was at the Cheshire Reginal Rehab center after she broke her hip in October. I was horrified about the lack of care she received there and I too made a complaint with the state but never heard back about my letter. I did however made several complaints to nursing staff , director, and admid and was met with the utmost rude people. My mother was admitted but my family never met with a dr once to discuss her case, care or plan. I put in several requests to talk with a dr and never even received a phone call. She was left with a catheter in for over 2 weeks and when we requested it be taken out it wasn’t…and she did get an infection. She wasn’t bathed, cleaned up and even missed 2 orthopedic appointments because of their lack of care. I found her crying in the hallway alone while nurses were just walking by ignoring her. She wasn’t eating but they still wouldn’t get a dr for us. We finally had her moved to another facility and guess what-a dr never even signed off on her release and her diagnosis was wrong on her release papers-they put down ailments she didn’t even have!!! It was an awful awful place!!! They should be closed!! It smelt like urine and the staff was rude and could care less!!

  3. This is disgusting. Would they want their loved ones treated this way? I know that many of the places are understaffed and underpaid but that is no excuse. These minimal fines will do nothing. The owners and administrators of these places should have to feel and undergo the mistreatment that these patients have had to endure.

  4. I have been a CNA for 3 years now and I love my job and my residents. They are my other family! This is disgusting on all parts, the facility administration, DORs, nursing staff and nursing support! I totally understand that working in a nursing home can and is hectic, and as a CNA my time management is key. But to let someone sit in a wet diaper for 11 hours is just plane lazy and they deserved to be fired and their licence taken from them. Would you like your mom, dad, brother or sister be treated like that! People really think before you get into the health care field, it is very hard but rewarding job!

  5. I have been in the healthcare industry for 20 plus years in sales/marketing roles. I am not a clinician so I’m not trying to come across as knowing more or understanding what they face everyday with patient care. I have done quite a bit of inservicing and training with the products and services I’ve represented. There are many challenges in getting facilities to get behind the educational efforts the staff – in many cases desperately need! The biggest offender is costs and limited budgets, that’s what administrators, directors, management, will tell you! The general systems mentality is ” we don’t need to reinvent the wheel” …. this may be true but it definitely needs some realigning! The changes need to come from top down no matter what size the organization is. Implementing this type of game plan is not easy and as the good employees are trying to do more with less accidents, serious avoidable consequences, will continue to take place every day! I hope I get to see when the companies with early adapters leading the way successfully educate their stockholders, board members, and the rest of the upper crust, that everyone wants their unfair share of the wealth but at what costs …. kind of like biting the hands that feed you! I guess if I was well off and kept getting large sums of money from the companies I had large number of shares in I might not want to think or hear about this either!