Nursing Homes Fined After Resident’s Death, Undocumented Injuries

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The state has fined an Avon nursing home where a resident died and a Bristol home where staff did not document how 10 residents suffered a total of 47 injuries.

In all, four nursing homes were recently fined by the state Department of Public Health (DPH) for various violations.

Apple Rehab Avon received two fines, totally $5,625, connected to a March incident in which a resident died and a nurse misinterpreted the medical file to contain a Do Not Resuscitate (DNR) Order, according to documents.

In the first citation, the facility was fined $3,000. According to the citation, on Feb. 24 the resident—who was bipolar and suffered from depression, atrial fibrillation and pulmonary embolism—signed an advance directive order waiving all advanced directives; it was signed by the attending physician and said, in part, that the resident wanted “efforts to prolong life and want(ed) life-sustaining treatment to be provided.”

Less than two weeks later, on March 2, a registered nurse checking on the resident found the resident with no heartbeat, not breathing, and pale and cool to the touch, according to DPH. The nurse looked at the resident’s file and “interpreted the code status as Do Not Resuscitate.”

The nurse told the attending physician that the resident had a DNR. The nurse obtained a RN Pronounce Order from the doctor and pronounced the resident dead, according to DPH.

The nurse was suspended immediately. In follow-up interviews, the attending physician said he assumed the nurse had read the code correctly and did not question giving the RN Pronounce Order, DPH said.

Following the incident, licensed staff members at the facility were educated on the importance of verifying advance directive documents and participated in a mock code drill.

The facility was also fined $2,625 for not following its policy regarding CPR, the second citation said. The policy says, in part, that CPR is the first treatment for someone who doesn’t have a DNR status and has no pulse and has stopped breathing, according to DPH. The policy says CPR should be initiated per physician’s orders.

A spokesperson for the facility could not be reached for comment.

Countryside Manor of Bristol was fined $3,000 for various violations in which staff didn’t know how 10 residents were injured.

Between August 2015 and May 2016, 10 residents sustained a total of 47 injuries, according to the citation. DPH found that in each case the cause of the injuries was unknown and that the staff failed to conduct proper investigations to try and find the causes.

The patients—who all had diagnoses such as Alzheimer’s disease, dementia and Parkinson’s disease and who depended on staff for help with mobility—suffered bruises, skin tears, rashes and, in one case, a swollen lip, according to DPH.

Officials at the facility did not respond to a call seeking comment.

New London Rehabilitation and Care of Waterford was fined $3,000 for an incident in which nurses failed to perform proper spot checks on residents and one resident left the facility.

The resident had Korsakoff Syndrome, a chronic memory disorder, as well as depressive order, anxiety and dementia, according to the citation. The resident, who was kept in a secured unit, had threatened to leave the facility multiple times and wore an ankle bracelet monitor.

According to the citation, staff realized the resident was missing during a routine check at 6 a.m. Feb. 13. The resident had shown up at a local hospital at 2:30 a.m. and was admitted for altered mental status after complaining of frostbite from hiking.

DPH found that staff failed to ensure they knew the resident’s whereabouts between 11:30 p.m. Feb.12 and 6 a.m. Feb. 13, despite policy dictating that spot checks were to be done. A nursing assistant later said that although she signed documentation stating she had done spot checks every 30 minutes, she didn’t actually look behind the resident’s privacy curtain and assumed the resident was in bed, according to DPH.

Also, staff did not properly page a “Dr. Hunt” code for the missing resident, as is policy, and didn’t realize how the resident had left until another resident was seen in an outdoor courtyard and staff noticed a nearby open window with a broken latch.

DPH requested from the facility an action plan in which all supervisors will be educated about protocols that staff providing direct care must follow. A registered nurse supervisor will be responsible for ensuring rounds are completed every two hours, and audits will be conducted to ensure compliance, according to the citation.

Officials at the facility did not respond to a call seeking comment.

Harrington Court in Colchester was fined $330 for a Jan. 16 incident in which one resident was mistakenly given another resident’s medications.

A registered nurse gave a resident—who suffered from congestive heart failure and other diagnoses, but was feeling well and alert—Oxycontin and insulin meant for another resident, according to DPH. The nurse realized as she left the resident’s room that she had administered the wrong drugs, and a physician was notified.

According to the citation, the resident became dizzy and lethargic and subsequently required Narcan and oxygen therapy. An investigation found the nurse administered the original medications without first checking the resident’s name band.

Officials at the facility did not respond to a call seeking comment.


One thought on “Nursing Homes Fined After Resident’s Death, Undocumented Injuries

  1. Re: New London rehabilitation center. Karma is reflected in the mirror. They should look further and pop in on a weekend afternoon.