State Fines Nursing Homes For Lax Resident Supervision, Falls, Medication Error

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Seven Connecticut nursing homes have been fined by the state Department of Public Health (DPH) for lapses in care that endangered or hurt residents.

Geer Nursing and Rehabilitation Center in Canaan was fined $10,000 after a resident with dementia inappropriately touched four other residents.

The resident came to the facility Feb. 27, from another nursing home and had a history of sexually inappropriate behavior, according to the citation. Geer documented four incidents of inappropriate touching of other residents between Feb. 28 and March 11.

After each incident, the resident’s care plan was updated with interventions but the resident wasn’t put on one-on-one supervision until April 2.

“We keep the health and safety of our residents as our number one priority,” said administrator Robert Powers. “Geer does not discriminate based on the complexity of a diagnosis and we remain committed to providing patient-centered care regardless of the difficulty of individual health needs. We disagree with the finding from this survey and have exercised our right to appeal.”

The facility appealed but ultimately paid the $10,000 DPH fine, Powers said. It has been fined $21,000 by the Centers for Medicare and Medicaid Services for the same incidents and is appealing that fine, he said.

Sharon Health Care Center was fined $10,000 after two residents were injured in falls.

A resident fell in a shower room Dec. 20, 2018, suffering a broken femur. The nurse aide left the resident in the shower room at the resident’s request. The resident was taken to an emergency department, and an investigation found the resident shouldn’t have been left alone in the shower.

Another resident fell from a bed onto the floor Sept. 6, 2018, suffering a 7-centimeter head laceration, according to DPH. The resident was taken to an emergency department, where seven sutures were applied.

RegalCare at New Haven was fined $10,000 for two instances.

When a resident was found unresponsive Feb. 1, staff administered the Heimlich maneuver and removed a piece of sausage from the resident’s airway, according to DPH. The resident was taken to a hospital, treated for respiratory failure, and returned to the facility Feb. 3. An investigation found that the resident was supposed to be on a soft-food diet but was served sliced sausage with lunch.

On Jan. 27, a nurse aide threatened and pointed a water bottle at a resident, according to DPH. The nurse aide was fired.

Masonicare Health Center in Wallingford was fined $8,640 after a nurse aide threatened a resident.

A resident with dementia said that on May 24, a nurse aide asked for money. The resident didn’t have any money and reported that the aide threatened harm, the citation said. The aide denied threatening the resident, but was fired May 29, after the allegation was substantiated, according to the citation.

“Masonicare takes great pride in our mission to provide a safe, comfortable and supportive environment for our patients, residents, families and employees,” said Ann Collette, vice president of strategy and business development. “As a result, we maintain a zero tolerance policy with regard to abuse. And while we uphold a firm policy that helps to ensure a safe and nurturing environment, we cannot comment on the status of a current or former employee.”

Hewitt Health & Rehabilitation Center in Shelton was fined $3,800 after a resident inappropriately touched two residents and a nurse aide at the facility. The incidents took place on Feb. 14, Feb. 21 and March 1.

After each incident the resident was taken to a hospital, but documentation failed to show that supervision was increased once the resident returned to the facility. Following the incidents, the facility educated staff that the resident was to remain within eyesight of staff while awake, and was prohibited from being near residents of the opposite sex.

Mansfield Center for Nursing and Rehabilitation was fined $3,060 after a resident was given an amount of morphine sulfate that was 10 times the dose ordered by a physician.

On May 29, the resident was given 50 milligrams of the medication, but the physician’s order said 5 milligrams should be administered. The resident was given an immediate dose of Narcan and taken to an emergency room, where two more doses of Narcan were administered.

According to the citation, a registered nurse at the facility didn’t look at the medication concentration before administering it. The nurse called a supervisor immediately after giving the dosage.

The event resulted from “human error,” administrator Jim Fidanza said. “Immediately after the incident, the center conducted a root cause investigation to help determine any opportunities to lessen the chance of future occurrences. An action plan involving policy and procedure review, staff re-education, and compliance audits was then put in to place.”

Hamden Rehabilitation and Health Care Center was fined $3,060 after a resident was hurt while being moved from a wheelchair to a bed.

The resident suffered a lower leg laceration when being transferred on March 25, according to DPH. The injury required 17 sutures. The resident’s care plan called for two staff members to help with transfers, and use of a pivot disk, but one nurse aide attempted the transfer without using the pivot disk.

Officials at Sharon Health Care Center, RegalCare at New Haven, Hewitt Health & Rehabilitation Center and Hamden Rehabilitation and Health Care Center did not return phone calls seeking comment.


More regulatory action: Bridgeport Hospital was fined $150,000 and sanctioned for specimen errors. Check out our hospital inspection database here for more information on all the state’s hospitals.

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