Eight Nursing Homes Fined Following Lapses In Care

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State health officials cited and fined eight nursing homes for various violations that resulted in lapses in care.

The Reservoir in West Hartford was fined $2,360 after staff failed to give a resident’s spouse proper written notice that the resident was being transferred to another facility. The resident was moved on July 12 and the resident’s spouse opposed the move because it was far from the spouse’s home.

The move came a week after the resident had left the facility despite being identified as an elopement risk and wearing a WanderGuard sensor, the Department of Public Health (DPH) citation said. Police found the resident in a wooded area about 50 feet behind the facility. Staff told the spouse that a state agency requested the transfer.

Officials at the facility did not return a call seeking comment.

Orchard Grove Specialty Care Center in Uncasville was fined $1,945 for two incidents.

A resident identified as a fall risk fell 14 times between Nov. 8, 2016, and April 27, 2017, according to DPH, and suffered a broken rib and other injuries. Interventions were added to the resident’s care plan following each fall, but staff failed to address the resident’s habit of removing alarms and clothing, according to the citation.

Also, a resident with dementia was found twice with empty or partially empty bottles of medication nearby. On March 6, the resident was found with an empty bottle of cough syrup, admitted to drinking half of it and was taken to a local emergency department. On May 9, the resident went to the hospital after a nurse’s aide found an empty bottle of cough syrup and half a bottle of liquid iron supplements in the resident’s nightstand drawer, according to the citation.

In light of the citation, staff identified areas for improvement and strive to provide individualized care to residents, said John Anantharaj, vice president of clinical services at parent company Apple Rehab.

“Orchard Grove continues to work with DPH and regulatory bodies to meet all standards of care,” he said.

Evergreen Health Care Center in Stafford Springs was fined $1,710 after a patient hit a doorframe while riding in a custom wheelchair, breaking a leg on Nov. 16, 2016. The resident was treated at a hospital and modifications were made to the wheelchair to make it safer, according to DPH.

“Evergreen Health Care Center takes very seriously our obligation to provide quality services to our residents,” said administrator Chris McKinney. “As a result of this incident, we have performed an internal review of our processes and will continue to look for ways to improve the care we provide to all our residents.”

Litchfield Woods Health Care Center in Torrington was fined $1,530 after a licensed practical nurse mistakenly administered nine medications to a resident.

On June 5, the resident received medications intended for a roommate, including several cardiac drugs, the citation said. An investigation found the LPN who administered the medications didn’t check the resident’s wrist ID band and the resident was treated at a local emergency department.

Officials did not return a call seeking comment.

Notre Dame Health and Rehabilitation Center in Norwalk was fined $1,530 after a resident with a seizure disorder didn’t receive a prescribed anti-seizure medication for 27 straight days.

The resident was taken to a hospital March 27, after suffering a seizure while being fed by a staff member, DPH said. An investigation found the resident hadn’t received the anti-seizure medication Depakote from March 1 to March 27, despite a physician’s order that it be administered twice daily, according to the citation.

The incident seems to be related to a computer error, according to administrator Dana Paul. The employee involved no longer works at the facility and new protocols were implemented to prevent similar errors from occurring, Paul said.

“It was an isolated situation,” Paul said. “We have rectified the situation. We’re definitely committed to making sure we maintain our high standard within the facility.”

Douglas Manor in Windham was fined $1,530 after a resident suffered several fractures and a 20-centimeter laceration after falling in a bathroom. The resident’s care plan required staff to use a gait belt when assisting with transfers, but two nurse’s aides failed to use the belt on June 4, DPH said. The resident was treated at a local hospital and both aides were suspended.

Officials did not return a call seeking comment.

Cook-Willow Convalescent Home in Plymouth was fined $1,530 after a resident suffered second-degree burns and blisters on several fingers from pureed food.

A nurse’s aide was helping the resident eat dinner on May 21, when the aide turned to get the resident’s coffee and the resident burned several fingers on pureed green beans. The holding temperature of the food was found to be 160 degrees, according to the citation, when protocol dictated hot foods shouldn’t exceed 135 degrees.

Officials did not return a call seeking comment.

Apple Rehab Saybrook in Old Saybrook was fined $720 after a resident was found unresponsive after a meal on April 28. A physician’s order said the resident, who had dementia and dysphagia, must be supervised when eating, but documentation didn’t show staff assisted the resident during breakfast that day, the citation said. The resident was treated at a local emergency department and returned to the facility.

Officials did not return a call seeking comment.

2 thoughts on “Eight Nursing Homes Fined Following Lapses In Care

  1. Sadly, it seems the State of CT only fines a few thousand dollars when a patient dies due to “mistakes” made by nursing homes. But at least the state looks into these facilities – assisted living facilities seem to have no oversight at all.