DPH Fines Three Nursing Homes Following Lapses In Care

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The state has cited and fined three nursing homes for various violations, including mismanagement of medication.

The state Department of Public Health fined Apple Rehab Rocky Hill $3,000 for seven incidents. One incident on Oct. 27, 2016, involved a resident’s hospitalization for an uncontrolled nosebleed. DPH found staff had mismanaged the resident’s anticoagulant medication prescriptions.

The resident, who suffered from congestive heart failure and other ailments, was supposed to be taken off Coumadin and begin taking Xarelto on Oct. 20, according to the citation. From Oct. 20 to Oct. 23, the resident received neither medication and then was given both medications in error for several days, the citation said.

While hospitalized on Oct. 27 for a nosebleed, the resident experienced “prolonged and vigorous retching” and required the use of a “non-invasive mechanical pressure support ventilation,” according to DPH. The resident was hospitalized until Nov. 15 before returning to the facility.

The other six of incidents involved residents developing pressure bedsores, or being put at risk of developing pressure bedsores. DPH found staff ignored care plans and did not place pillows under residents’ feet to alleviate pressure, according to the citation.

John Anantharaj, the facility’s vice president of clinical services, said Apple Rehab of Rocky Hill “provided immediate education for all staff to improve the quality of care and rectify the [DPH] findings. Apple Rehab of Rocky Hill is committed to working with DPH and other regulatory agencies to ensure that excellence in care is provided to all our residents.”

Westport Rehabilitation Complex was fined $2,330 for five incidents that occurred in 2015 and 2016.

In one case, staff gave incorrect medications to a resident’s family member who took the relative home for an overnight visit on May 29, 2016. The family member was sent home with two drugs, Clozapine, an anti-psychotic drug that the resident’s physician did not order, and Omeprazole, a heartburn medication, which the physician had discontinued two months prior.

After noticing behavior changes, according to DPH, the family member took the resident to the hospital, where the resident had an abnormally slow heartbeat, which can be a side effect of Clozapine. After being monitored in the intensive care unit, the resident was discharged and returned to the facility on June 1.

A nurse failed to check the physician’s medication orders before giving the drugs to the family member, the citation said.

In a separate instance, a resident was found wandering on Post Road on Jan. 24, 2016, and was returned via police escort, the citation said. The resident was seen trying to leave the building several times between Jan. 21 and Jan. 24, getting as far as the facility’s lobby.

According to DPH, the facility failed to document whether an investigation of the incident took place. The resident was wearing a “wanderguard” sensor, and it is unclear how the wanderguard alarms were bypassed, the citation said.

Other violations at the facility involved staff’s failure to investigate the cause of a resident’s bruises and broken finger; failure to investigate a resident’s claim of mistreatment by a nurse’s aide; and failure to follow a care plan, which resulted in a resident falling from a wheelchair.

The facility’s executive director, Anna Durkovic, said, “Our residents’ wellbeing is always our top priority. After addressing the concerns identified by DPH, Westport Rehabilitation Complex is back in compliance.”

Talmadge Park East Haven was fined $1,160 for an incident dating back to 2012 in which a nurse’s aide forcibly pulled a resident into a chair, according to DPH.

The citation said a resident with advanced dementia was yelling on Dec. 15, 2012, while two nurse’s aides were talking to each other nearby. Witnesses told investigators the resident was in a wheelchair and tried to stand up and one of the nurse’s aides forcibly pulled the resident back down into the wheelchair from behind. That nurse’s aide subsequently was fired.

The citation was issued in 2013, but DPH just publicly released the information because the facility recently paid the fine, according to Maura Downes, DPH spokeswoman. Talmadge Park requested a formal hearing to contest the citation, but later withdrew the request and paid the fine.

“The facility strives to provide quality care to all its residents and took appropriate action in 2013 regarding this event,” said Michael Fiore, the facility’s administrator. “All staff receive ongoing education regarding standards of care.”

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