Nursing Homes Fined For Putting Residents At Risk

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Six nursing homes have been fined by the state Department of Public Health (DPH) for violations that resulted in residents being endangered or injured.

Noble Horizons in Salisbury was fined $6,660 for incidents related to elopement risks.

On Sept. 23, 2018, a resident with dementia left the facility when a WanderGuard sensor malfunctioned. A driver in a pickup truck found the resident walking down the facility’s driveway. A registered nurse entering the driveway spotted the resident in the truck and returned the resident to the facility, the citation said.

The resident left through a door that should have locked when a resident wearing the WanderGuard approached the door, according to DPH. Also, the resident should have been reassessed for elopement risk following the incident, but documents did not show that was done.

Separately, documentation from April 1 through Sept. 30, 2018, did not show that another resident’s WanderGuard was monitored for proper placement or function, according to the citation.

Also, the facility failed to conduct weekly checks of all doors equipped with wander alert devices, such as alarms, to ensure that they were working properly, the citation said. A staff member responsible for the checks said that he couldn’t remember the last time he did checks and indicated that it had been “quite some time.”

St. Joseph’s Living Center in Windham was fined $6,000 after a licensed practical nurse (LPN) was seen improperly cleaning a glucometer.

On Sept. 27, 2018, the LPN cleaned a glucometer with a sanitizing wipe, and had done so after each test of several residents’ blood sugar. According the citation, the glucometer’s manufacturer said a different type of wipe is the only kind that should be used on the device. The director of nursing services didn’t know the wipes being used by staff weren’t the recommended wipes, according to DPH.

“St. Joseph Living Center practices the highest standards of infection control. Although a CDC-approved Sani-wipe was used to disinfect blood-borne pathogens, the manufacturer of the glucometer recommended a different Sani-wipe,” said Ginny Person, St. Joseph’s administrator. “The facility responded immediately and was put back into compliance by DPH.”

Woodlake at Tolland Nursing and Rehabilitation Center was fined $3,720 after a resident fell from a bed to the floor while receiving incontinence care.

On April 7, 2018, a nurse aide rolled the resident onto the left side and the resident’s feet went over the edge of the bed. According to the citation, the aide tried to stop the resident from falling but couldn’t.

The resident, who was identified as a high risk for falls, suffered acute blunt knee trauma and a femoral fracture, and was sent to a hospital. It was unclear whether one or two staff should have been helping with bed mobility, according to DPH, and staff weren’t sure whether there was a physician’s order in place regarding the number of staff required.

Advanced Center for Nursing and Rehabilitation in New Haven was fined $3,060 after a resident obtained contraband for another resident.

On June 18, 2018, a resident with diagnoses of alcohol intoxication and withdrawal was found lying in a courtyard lethargic and unresponsive to verbal stimuli. According to DPH, the resident had “some drinks” before smoking marijuana obtained from another resident.

The resident was taken to a hospital, given Narcan, and tested positive for cannabinoids, alcohol and cocaine. An investigation found the resident had gotten the “contraband substance” from another resident, who obtained it during a 42-minute leave of absence request, according to DPH. An investigation also found facility documentation misclassified the incident.

Administrator Daniel Brencher declined to comment, saying he was legally prohibited from discussing resident-specific information.

Cassena Care at New Britain was fined $1,530 for an incident in which a resident was hospitalized after passing a 3-foot-long blood clot.

After the resident passed a clot “resembling intestines” from the rectum on Friday, June 22, 2018, an advanced practice registered nurse was notified and directed staff to monitor the resident’s vital signs for 72 hours and re-evaluate the resident on Monday, according the citation. But the resident was taken to a hospital on June 23 with hypoactive bowel sounds, nausea and vomiting and weakness, and was diagnosed with gastrointestinal bleeding.

Apple Rehab Laurel Woods in East Haven was fined $1,080 after a resident with dementia was restrained in a wheelchair when a nurse aide tied a sheet around the resident’s waist.

The resident became agitated on March 4, 2018, while being put into a wheelchair by two nurse aides and a nurse. According to DPH, one of the nurse aides later tied a sheet around the resident’s waist. The nurse aide was terminated when the allegation of abuse was substantiated.

Officials at Noble Horizons, Woodlake at Tolland, Cassena Care, and Apple Rehab did not return a phone call seeking comment.

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