State Fines Nursing Homes For Lapses In Care, Resident Death

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Five Connecticut nursing homes have been fined by the state Department of Public Health (DPH) following lapses in care, including one incident after which a resident died.

Jewish Senior Services of Bridgeport was fined $3,060 after a resident with multiple sclerosis died after falling from a bed onto the floor. On June 12, 2018, a registered nurse was applying protective dressings to the resident’s coccyx, turned away to dispose of the dressing wrappers and, when she turned back toward the resident, saw the resident was starting to fall, according to the citation. The RN tried to stop the fall but couldn’t.

The RN had moved the patient without help, even though the resident’s care plan called for two-staff assistance with mobility, according to the citation. The RN told investigators she typically repositioned the resident without having a second staff member assist.

The resident was diagnosed at an emergency department with a high spinal cord trauma, intracranial hemorrhage and two femur fractures, and subsequently died. According to DPH, documentation failed to show that a neurological assessment was done at the time of the fall and failed to note a change in condition when the resident complained of pain and impaired vision after initially denying any discomfort.

A clinical nursing director said staff were unable to determine what caused the resident to fall, according to the citation. Since the incident, residents who can’t maintain a safe lying position are given bolsters and assisted by two staff members for repositioning.

“We at Jewish Senior Services were saddened by the accidental death of a beloved resident last June,” said Senior Vice President Lawrence Condon. “We have cooperated with the state’s investigation into this isolated incident, and while we viewed this as an accident and contested their findings, we have provided additional training and education to staff members who work with residents in the hope of preventing such accidents from occurring in the future. There is no greater priority at Jewish Senior Services than the safety and well-being of the residents in our care, and we take very seriously the trust that residents and their loved ones place in us.”

Meriden Center was fined $3,270 after a resident suffered a leg laceration while being transferred by a nurse aide.

The aide was moving the resident from a wheelchair to a bed on Dec. 23, 2017, when the resident’s left leg became caught under the bed. According to the citation, the resident suffered a 16-centimeter laceration and was taken to an acute-care facility, where sutures were applied.

“Meriden Center is committed to providing high-quality care to our patients and residents,” said spokeswoman Carol Albright Rohrbaugh. “Since that time [of the citation] we provided additional staff education and training, and submitted a plan of correction to the state.”

Cassena Care at Stamford was fined $3,060 after a resident acquired a severe pressure ulcer and several skin tears at the facility.

On Aug. 20, 2018, the resident had a Stage 3 pressure ulcer on the lower back, a skin tear on the left groin, and two skin tears on a left above-the-knee amputation stump, according to DPH.

The pressure ulcer had been diagnosed a week prior and recommendations were made, including limiting the resident’s sitting to 60 minutes. But on Aug. 20, staff went in and out of the resident’s room during a nearly four-hour period but the resident stayed in the same position in bed, the citation said.

When eventually repositioned, the resident complained of pain in the left elbow, which had become red.

Officials at the facility didn’t return a call seeking comment.

The Villa at Stamford was fined $3,060 after a resident was hit in the face by a Hoyer lift crossbar.

Two nurse aides who were transferring the resident into a chair on April 16, 2018, said the lift “tilted” and struck the resident in the face. According to the citation, the resident suffered a laceration above the left eye that needed sutures at a local emergency room.

The nurse aides were in-serviced on proper transfer technique and padding was added to the lift crossbar, according to DPH. After the incident, the director of nursing services said the lift likely hadn’t tilted but the resident may have leaned into the lift, and that the cause of the injury was unclear.

Staff were retrained and educated following the event, and the organization continues its mission to provide high-quality care to all residents, said administrator Peter Showstead.

Golden Hill Rehab in Milford was fined $1,080 after a resident with dementia left the facility.

After last being seen at 3:30 p.m. on July 2, 2018, the resident left and later returned to the facility at 5:45 p.m., according to the citation. A staff member saw the resident walking about a mile away and returned the resident to the facility.

The resident was a known elopement risk who had talked about or attempted leaving on June 10, 11, 13, 18 and 29. During the June 13 incident, the resident wasn’t wearing a WanderGuard sensor, a new one was applied, and the resident was later seen again not wearing one. After that, according to DPH, a physician’s order discontinued the WanderGuard and directed staff to check on the resident every 15 minutes.

An investigation found checks on July 2 were not completed between 3:15 and 5:45 p.m.

Officials at the facility didn’t return a call seeking comment.

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