State Fines Two Nursing Homes

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The state has fined two nursing homes in connection with staff failing to follow notification procedures for changes in residents’ conditions and for a resident who fell and broke a bone.

Evergreen Health Care Center in Stafford Springs received two citations and fines, totaling $3,890. In one citation, Evergreen Health was fined $2,360 for failure to follow facility procedures and notify a physician on condition changes of two residents.

On March 1, a resident with heart failure, anxiety and dementia complained of seeing spots out of the left eye. A neurological assessment was done, which produced normal results, but the resident continued to complain of a sight problem, according to the state Department of Public Health (DPH). The resident later was taken to a hospital and diagnosed as having a retinal artery occlusion in the left eye, according to the citation. The citation said that a licensed nurse practitioner and registered nurse assessed the resident, but the findings were only reported to a nursing supervisor and not a physician.

On March 9, a resident with dementia and gastro-esophageal reflux complained to staff of stomach pain and nausea, and was vomiting. The resident declined medications, according to the DPH citation. The resident subsequently was taken to a hospital, admitted and diagnosed with a small bowel obstruction from adhesions. The physician was not notified of the resident’s change in condition, as required by facility procedure.

In a second citation, Evergreen Health was fined $1,530 for staff failure to notify a doctor of the changing condition of the same resident suffering from stomach pain, nausea and vomiting.

Officials at Evergreen Heath Care Center, which is operated by Stafford Springs CT SNF LLC, did not respond to requests for comment.

Parkway Pavilion Health & Rehabilitation Center in Enfield was fined $2,070 for two incidents.

In one incident, a resident fell out of bed and broke a left arm bone on April 15, according to DPH. A nursing assistant had intended to move the resident, who suffered from Alzheimer’s disease and dementia, out of bed when a fire alarm sounded. Upon hearing the alarm, the nursing assistant left the resident in bed, exited the room and closed the door, according to the DPH citation. The nursing assistant failed to leave mats on the floor or pillows around the resident, as required in the care plan, the citation said. After the fire alarm had been cleared, a housekeeper found the resident facedown on the floor in the room.

In a separate incident, a resident who suffered from delirium due to a physiological condition left the facility and walked down Route 5—a busy road—to a cemetery on Dec. 3. DPH investigators found that a speech therapist had let the resident go outside but failed to notify staff.

Nancy Luddy, the facility’s administrator, said, “The citation identified by the Department of Public Health was related to separate and isolated incidents involving individual residents. Staff has received in-service education and the facility remains committed to providing the highest quality of care to the residents it serves.”


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