Three Nursing Homes Fined Following Lapses In Care

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The state Department of Public Health (DPH) has fined three Connecticut nursing homes for violations that injured residents or jeopardized their safety.

Autumn Lake Healthcare at New Britain was fined $3,000 after staff incorrectly used a ventilator machine on a resident.

On Feb. 2, 2017, a resident with chronic respiratory failure and chronic obstructive pulmonary disease complained of shortness of breath and was put on a trilogy machine, a type of non-invasive ventilator, after other interventions failed to help, according to DPH. The resident was placed on the machine but continued to complain of shortness of breath and subsequently was taken to a hospital for observation and returned to the facility the next day, according to the citation.

An April 3 DPH investigation found the trilogy machine’s cuff pressure—an indicator that helps ensure the ventilator is working properly— had been titrated incorrectly and staff had not been trained in how to use the device.

A registered nurse, who documented using the machine, admitted not knowing how to use the machine and never touched it, according to the citation. The RN told investigators that a licensed practical nurse titrated the cuff pressure. But when questioned by DPH, the LPN didn’t recall the incident and did not know how to use the machine.

The investigation also found incomplete documentation and a failure to assess the resident in accordance with policy, according to DPH.

As a result of the incident, DPH ordered and received an immediate action plan from the facility that says it will not admit any residents who require use of a trilogy machine. Also, all licensed staff and respiratory therapists will be taught how to use the machine and other non-invasive ventilators, the citation states.

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

Avalon Health Care Center at StoneRidge in Mystic was fined $1,530 after a resident was injured on two separate occasions during wheelchair transfers.

On Sept. 14, 2016, the resident, who was a known risk for skin breakdown, sustained a skin tear on the left leg when the leg hit a wheelchair leg rest as the resident was being transferred in a bathroom. On Nov. 5, 2016, the resident was taken to an emergency department and needed 13 sutures after suffering a 7-centimenter-long leg laceration after hitting a leg on a wheelchair leg rest, according to DPH.

In the second incident, a nurse’s aide received “disciplinary action” for folding up the leg rests, rather than removing them in accordance with facility policy.

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

Birmingham Health Center in Derby was fined $330 after a resident, who is monitored with a WanderGuard ankle sensor, left the facility. A DPH investigation found that the resident had been on a medical absence and returned to the facility on July 19. On return, staff failed to place the WanderGuard ankle sensor on the resident’s leg.  On July 20, the resident, who suffers from vascular dementia and atrial fibrillation, was reported missing at 1:25 a.m. The resident was found down the street and returned to the facility at 1:38 a.m.

Officials at the facility did not respond to a request for comment.



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