DPH Fines Nursing Homes After Errors Result In Injuries, Amputation, Falls

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Five nursing homes have been fined by the state Department of Public Health (DPH) for errors that endangered or injured residents.

Regency House Nursing and Rehabilitation Center of Wallingford was fined $10,000 for two violations.

On Sept. 14, 2018, a resident suffered a calf laceration that needed 10 sutures after a wheelchair rolled into a bed frame. A nurse aide wheeled the resident in front of a bathroom door and walked to a dresser to get a comb when the wheelchair continued to roll. According to DPH, the nurse aide was re-educated on the importance of wheelchair brakes.

On Aug. 7, 2018, a resident had swollen cheeks along with white patches on the left cheek and gum line, according to DPH. An investigation found that in the days leading up to then, the resident erroneously received 11 extra doses of methotrexate, which is used to treat rheumatoid arthritis. The resident should have received 10 milligrams per week of methotrexate, but a registered nurse mistakenly transcribed the order as 10 milligrams per day.

The resident was treated for methotrexate toxicity and transferred to a hospital Aug. 13, 2018, for a platelet transfusion. Following the incident, all methotrexate orders at the facility were to be flagged with an alert, according to the citation.

Ridge Crest at Meadow Ridge in Redding was fined $9,060 after a resident developed gangrene and needed an above-the-knee amputation.

The resident was admitted to the facility June 13, 2017, following an operation at a hospital for a right leg ulcer. Staff failed to conduct weekly wound assessments between June 13 and Sept. 4, 2017. Staff also failed to assess the resident’s circulation between June 13 and Sept. 26, 2017, according to DPH.

The resident was taken to a hospital Sept. 26, 2017, diagnosed with gangrene and had the amputation. In addition to other errors, staff failed to properly notify physicians of changes in the resident’s condition, according to DPH. Following the incident, the facility submitted a corrective action plan to DPH that includes skin assessments for all residents.

The violation was a “single and isolated” incident, said spokeswoman Jennifer Whittle.

“We continue to be dedicated to providing the highest standards of care at Ridge Crest at Meadow Ridge,” she said.

Apple Rehab Coccomo in Meriden was fined $6,120 after a resident fell while being transferred.

A nurse aide tried to move the resident from a wheelchair to a toilet without help, even though the resident’s care plan called for two-staff assistance with all transfers. The resident fell and was taken to a hospital, according to DPH.

The resident was diagnosed with fractures of the tibias, fibulas and left humerus. According to the citation, the nurse aide transferred the resident without help and didn’t use a gait belt. The nurse aide had moved the resident alone earlier in the day without a problem, and didn’t check the resident’s care card for transfer instructions. The nurse aide was terminated for twice failing to follow the plan of care, according to DPH.

Meridian Manor Corp. in Waterbury was fined $3,000 after a resident who was prohibited from leaving independently continued to do so repeatedly.

The resident previously had been allowed to take leaves of absence independently with a car, but on April 26, 2017, an advanced practice registered nurse determined the resident could no longer do so because the resident had low blood sugar, declining renal function, had become hostile, was returning late from leaves, and had missed medications and treatments, according to DPH.

A leave of absence sign-out book showed the resident left the facility independently, almost daily, from May 3 to May 21, 2017. On one trip, the resident obtained a prescription for Oxycodone at a walk-in clinic in the community. On June 1, 2017 the resident signed out for a leave, fell at a family member’s house and suffered facial bruises and skin tears.

The resident continued to leave the facility, according to the citation. On June 16, 2017 the resident was admitted to a hospital and diagnosed with congestive heart failure. Following the incident, the facility implemented a corrective action plan that included educating all licensed staff, according to DPH.

The Hebrew Center for Health and Rehabilitation in West Hartford was fined $1,320 after a resident was sent on a leave of absence with another resident’s medications. The resident was diagnosed with hypoglycemia and treated with intravenous fluids at a hospital on Dec. 24, 2018, according to DPH.

An investigation found that the resident had been sent home on a leave of absence three days earlier with the resident’s medications, as well as several medications intended for another resident. As a result, the resident received an extra dose of Losartan, which is used to lower the risk of strokes in patients with high blood pressure; aspirin; and diabetes medication Januvia, according to the citation.

Officials at the Regency House, Apple Rehab Coccomo, Meridian Manor and the Hebrew Center, did not return calls seeking comments.

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