Nursing Homes Fined Following Resident Elopements, Injuries

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Four nursing homes have been fined by the state Department of Public Health (DPH) for various violations that jeopardized residents’ safety or caused injuries.

Western Rehabilitation Care Center in Danbury was fined $10,000 following several incidents.

On Nov. 15, 2019, a licensed practical nurse (LPN) mistakenly discharged a resident with another resident’s medications. The error was realized on Nov. 18, after a family member had given the resident the incorrect medications for two days and the resident grew increasingly drowsy, according to DPH. The LPN was rushing during discharge and wasn’t certain that the medications were verified, the citation said. The LPN was re-educated about medication administration.

On Nov. 8, 2019, a resident left the facility for five days, returning after police issued a Silver Alert and later found the resident at home.  The resident spoke about wanting to go home since being admitted, but staff couldn’t substantiate that an elopement assessment had been done and failed to follow-up on obtaining a physician’s order for a WanderGuard, according to the citation.

On Dec. 3 the same resident was found in a stairwell trying to gain access to the facility. Staff members were re-educated about the importance of securing all exits, according to DPH.

On Dec. 4, a surveyor pushed open a door that was supposed to require a security code for opening. According to DPH, an alarm sounded for 12 minutes before a staff member silenced it. DPH found annunciators, which notify staff of an alarm, were faulty.

Also, a review of records from March 9 to April 30, 2019, found no documentation that oxygen saturation levels were checked, as ordered by a physician, on overnight shifts for a resident with chronic obstructive pulmonary disease.

Arden House in Hamden was fined $7,800 after a resident fell and was injured while being transferred from a wheelchair to bed by two nurse aides.

The aides were moving the resident with the help of a mechanical lift on July 9, 2019, when the resident fell mid-transfer, the citation said. One aide was operating the lift, and the other should have been holding the resident steady, but instead turned to move the wheelchair out of the room, the citation said. The resident was treated at a hospital for hip and femur pain and received one staple for a head laceration.

Bel-Air Manor Nursing and Rehabilitation Center in Newington was fined $6,960 after a resident fell and suffered several spinal fractures while being moved in a lift.

Two nurse aides were transferring the resident from a bed to a wheelchair on Dec. 9, 2019, when the resident fell out of the lift sling, DPH said. The resident was taken to a hospital and diagnosed with fractures, which were treated non-surgically. The lift was taken out of service, one nurse aide was suspended pending an investigation, and all nursing staff members were re-educated on mechanical lift policies and procedures, according to DPH.

“We take patient safety and well-being very seriously,” said administrator Marianne Herold. “We’re working with the state to address the alleged identified issues and have put the appropriate corrective measures in place. We strive for excellence and follow our corrective measures through the quality improvement process.”

Pendleton Health and Rehabilitation Center in Mystic was fined $6,120 after a resident fell out of bed as a nurse aide repositioned a pillow.

After the Sept. 3, 2019, fall, the resident was treated at a hospital for a left femur fracture and toe abrasion, according to DPH. The aide knew the resident required two-staff assistance for most care, but repositioned the pillow without help.

“Following the survey, the center diligently developed and implemented a plan to correct the findings identified,” said spokesperson Annaliese Impink. “Approximately one month later, a follow-up inspection by the Department of Health held on Jan. 23, 2020, determined that the center had corrected the findings and was back in compliance. We appreciate the efforts of our staff to correct the findings identified. We continue to work hard to provide quality care and services for the residents we have the privilege to serve every day.”

Western Rehabilitation and Arden House did not return phone calls seeking comment.

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