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.

Jewish Senior Services of Bridgeport was fined $3,060 after a resident with multiple sclerosis died after falling from a bed onto the floor. On June 12, 2018, a registered nurse was applying protective dressings to the resident’s coccyx, turned away to dispose of the dressing wrappers and, when she turned back toward the resident, saw the resident was starting to fall, according to the citation. The RN tried to stop the fall but couldn’t.

The RN had moved the patient without help, even though the resident’s care plan called for two-staff assistance with mobility, according to the citation. The RN told investigators she typically repositioned the resident without having a second staff member assist.

The resident was diagnosed at an emergency department with a high spinal cord trauma, intracranial hemorrhage and two femur fractures, and subsequently died. According to DPH, documentation failed to show that a neurological assessment was done at the time of the fall and failed to note a change in condition when the resident complained of pain and impaired vision after initially denying any discomfort.

A clinical nursing director said staff were unable to determine what caused the resident to fall, according to the citation. Since the incident, residents who can’t maintain a safe lying position are given bolsters and assisted by two staff members for repositioning.

“We at Jewish Senior Services were saddened by the accidental death of a beloved resident last June,” said Senior Vice President Lawrence Condon. “We have cooperated with the state’s investigation into this isolated incident, and while we viewed this as an accident and contested their findings, we have provided additional training and education to staff members who work with residents in the hope of preventing such accidents from occurring in the future. There is no greater priority at Jewish Senior Services than the safety and well-being of the residents in our care, and we take very seriously the trust that residents and their loved ones place in us.”

Meriden Center was fined $3,270 after a resident suffered a leg laceration while being transferred by a nurse aide.

The aide was moving the resident from a wheelchair to a bed on Dec. 23, 2017, when the resident’s left leg became caught under the bed. According to the citation, the resident suffered a 16-centimeter laceration and was taken to an acute-care facility, where sutures were applied.

“Meriden Center is committed to providing high-quality care to our patients and residents,” said spokeswoman Carol Albright Rohrbaugh. “Since that time [of the citation] we provided additional staff education and training, and submitted a plan of correction to the state.”

Cassena Care at Stamford was fined $3,060 after a resident acquired a severe pressure ulcer and several skin tears at the facility.

On Aug. 20, 2018, the resident had a Stage 3 pressure ulcer on the lower back, a skin tear on the left groin, and two skin tears on a left above-the-knee amputation stump, according to DPH.

The pressure ulcer had been diagnosed a week prior and recommendations were made, including limiting the resident’s sitting to 60 minutes. But on Aug. 20, staff went in and out of the resident’s room during a nearly four-hour period but the resident stayed in the same position in bed, the citation said.

When eventually repositioned, the resident complained of pain in the left elbow, which had become red.

Officials at the facility didn’t return a call seeking comment.

The Villa at Stamford was fined $3,060 after a resident was hit in the face by a Hoyer lift crossbar.

Two nurse aides who were transferring the resident into a chair on April 16, 2018, said the lift “tilted” and struck the resident in the face. According to the citation, the resident suffered a laceration above the left eye that needed sutures at a local emergency room.

The nurse aides were in-serviced on proper transfer technique and padding was added to the lift crossbar, according to DPH. After the incident, the director of nursing services said the lift likely hadn’t tilted but the resident may have leaned into the lift, and that the cause of the injury was unclear.

Staff were retrained and educated following the event, and the organization continues its mission to provide high-quality care to all residents, said administrator Peter Showstead.

Golden Hill Rehab in Milford was fined $1,080 after a resident with dementia left the facility.

After last being seen at 3:30 p.m. on July 2, 2018, the resident left and later returned to the facility at 5:45 p.m., according to the citation. A staff member saw the resident walking about a mile away and returned the resident to the facility.

The resident was a known elopement risk who had talked about or attempted leaving on June 10, 11, 13, 18 and 29. During the June 13 incident, the resident wasn’t wearing a WanderGuard sensor, a new one was applied, and the resident was later seen again not wearing one. After that, according to DPH, a physician’s order discontinued the WanderGuard and directed staff to check on the resident every 15 minutes.

An investigation found checks on July 2 were not completed between 3:15 and 5:45 p.m.

Officials at the facility didn’t return a call seeking comment.

On Oct. 29, Sheriden Woods Health Care Center of Bristol was fined $1,580 when records show a resident with a venous ulcer on a toe did not get follow-up care with a vascular surgeon in September.  A doctor’s visit had been cancelled and records show a lack of follow-up care for a few weeks until a doctor saw the wound on Sept. 26.

Aurora Senior Living of Norwalk was fined $1,280 on Oct. 31 in connection with an incident on Sept. 22 in which a resident who needed assistance to use the toilet reported he or she was told by a nurse’s aide to “do it on” him or herself. The person soiled him or herself and it was later determined that two aides had taken their break together, resulting in inadequate staffing, DPH records show.

Glendale Center of Naugatuck was fined $1,160 on Sept. 4 in connection with a July 14 incident in which a resident sustained a cut on the head after partially falling out of a mechanical lift while being transferred into a wheelchair, DPH records show.

The resident’s head struck a bed frame during the transfer, and the cut needed six staples to close it, records show. An investigation determined that aides used the wrong type of pad during the lift and that the home’s records failed to be specific on what type of lift pad should be used.  The incident prompted the home to require that three staff members lift the person, records show.

Jeanne Moore, a Glendale Center spokesperson, said the home submitted a plan of correction to the state and is in full compliance with state and federal regulations.

“Glendale Center received a deficiency in a routine annual survey conducted at our center in August that resulted in a fine,” she said. “We provided additional staff education and training on the topic of lifts and transfers.”

DPH records show that on Oct. 28, Gardner Heights Health Care of Shelton was fined $1,090 in connection with a Sept. 16 incident in which a resident sustained a cut on the leg that required 18 stitches. The resident was cut while moving from a wheelchair to a toilet when a student nurse failed to follow the plan of care and assist the person using a gait belt, DPH records show.

Cassena Care of Norwalk was fined $360 on Oct. 29 in connection with a resident who broke a shinbone in February, apparently when one nurse’s aide, instead of the required two, transferred the person from a wheelchair to a bed using a mechanical lift. The nurse’s aide reported ringing a bell for assistance during the lift, but then admitted lifting the person without waiting for help, DPH records show.

Officials from the other four nursing homes did not respond to calls seeking comment.