Nursing Homes Fined After Resident’s Death, Injuries, Medication Error

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The state has fined six nursing homes for violations that jeopardized residents’ safety, including an incident in which resident with Alzheimer’s was found dead outside a facility in Wallingford.

The facilities were fined by the state Department of Public Health (DPH) for violations that occurred between September 2019 and February 2020.

Skyview Rehab and Nursing of Wallingford was fined $10,000 after a resident with Alzheimer’s disease left the facility in January and was found dead about 50 feet from the facility, DPH said.

Staff noticed the resident was missing at 7:30 a.m. on Jan. 26, and the resident was found at 8:46 a.m., DPH reported. The resident was found wearing only a shirt and one sock, with bloody knees and muddy feet, according to the citation.

An investigation found the resident was last seen by a roommate on Jan. 25 between 9:30 and 10 p.m., and that staff hadn’t performed required regular two-hour visual check-ins with residents. A review of the facility’s staffing sheet showed there were only three nurse aides on duty, not the required four aides for the 11 p.m. to 7 a.m. shift, according to DPH.

A woman who answered the phone in the administration department declined to comment.

The Nathaniel Witherell nursing home in Greenwich was fined $10,000 after staff mistakenly let a resident with dementia leave the facility.

On Sept. 5, 2019, the resident, who wore a WanderGuard sensor, asked a receptionist for a ride home. The receptionist thought the resident was a visitor and called a taxi. The resident’s WanderGuard set off a door alarm as the resident left, but the receptionist claimed not to have heard it, and a housekeeper silenced the alarm without checking what triggered it or telling anyone, according to the citation. The resident returned by taxi about 15 minutes later, once staff realized a resident had left.

Following the incident, photos of all residents at risk for elopement were posted at the nurses’ stations and main reception area, according to the citation.

Groton Regency Center was fined $10,000 for several violations.

On Jan. 25, a resident suffered burns after falling out of bed and hitting a nearby baseboard radiator. According to DPH, the resident had a fever and was observed by a nurse aide as becoming increasingly restless that day, repeatedly trying to get out of bed. The aide failed to report the resident’s agitated behavior to a nurse supervisor. The resident was taken to a hospital and treated for leg burns and pneumonia. Following the incident, staff was re-educated and rooms were inspected to ensure beds were at safe distances from radiators, according to the citation.

On Feb. 13, a radiator was observed with its cover hanging down, exposing the heating element for more than an hour – during which time multiple staff who were in the room failed to report it, according to DPH. The cover exposed a sharp, jagged edge. Also, in one room there were only 18 inches between the bed and a wall, not the required three feet of clearance.

“Groton Regency Center is committed to providing high-quality care to our patients and residents,” said Lori Mayer, an administrator.  “Unfortunately, we did receive a Citation from the Department of Health earlier this year.  Since that time, we provided additional staff education and training, and submitted a plan of correction to the state.  At this time, we are in compliance with state and federal regulations.”

Orchard Grove Specialty Care in Uncasville was fined $9,480 after a resident was injured while being improperly transferred by a nurse aide.

On Sept. 14, 2019, an aide was moving a resident from a bed to a wheelchair when the resident suffered a leg laceration that needed nine sutures at a local hospital, DPH said. The resident’s care plan called for the assistance of two staff and a Sera (or sit-to-stand) lift for all transfers. At the time, the nurse aide was the only one working on that unit and was unaware of the resident’s care plan. The nurse aide tried to move the resident without assistance and without the lift, the citation said.

Salmon Brook Rehab and Nursing in Glastonbury was fined $6,120 after a medication error made on Aug. 14, 2019, sent a resident to the hospital with an overdose. A registered nurse was hurrying and mistakenly transcribed the resident’s dosage order for the antipsychotic medicine Zyprexa as 12.5 milligrams in the morning, 25 milligrams at night, and 12.5 milligrams every 12 hours as needed for agitation, according to DPH. The actual dosages prescribed for the resident were 1.25 milligrams in the morning, 2.5 milligrams in the evening, and 1.25 milligrams as needed.

Glendale Center in Naugatuck was fined $5,000 after an inspection on Feb. 4 found “pervasive significant” black mold on walls in the Dietary Department dish room, which was under renovation, according to DPH.

James Murphy, Glendale Center’s executive director, said workers discovered black mold behind a wall as they began a planned renovation project of the dish room. The facility notified DPH as a courtesy, and DPH inspectors visited and subsequently fined the facility, he said.  The renovation continued and the mold was removed.

Officials at the Nathaniel Witherell, Orchard Grove Specialty Care, and Salmon Brook Rehab and Nursing didn’t return calls seeking comment.

This story was updated from the previous version.

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