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.
]]>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.
]]>Apple Rehab West Haven was fined $6,960 after a resident reported being sexually assaulted by a visitor.
On Oct. 2, 2018, a licensed practical nurse (LPN) saw the resident and a male visitor naked in the resident’s room, and the resident told the LPN they’d just had sex, according to DPH. The LPN asked the resident several times if she was alright and the resident replied that the male was her boyfriend. The LPN reported the incident to the director of nursing and asked if the resident’s guardian should be notified, but the director said there was nothing they could do if the sex was consensual.
The following morning, the resident—exhibiting injuries on the neck, back and right leg—reported to a RN that she was sexually assaulted, the citation said. The resident was taken to a hospital and a rape kit tested positive, the citation said.
DPH said a nurse aide had failed to find out who the visitor was before showing him to the resident’s room, and the resident, who suffered from a developmental disorder, was unable to make an informed decision to consent to sexual relations.
Regalcare at Southport was fined $10,000 for several violations. A resident with dementia fell six times between Oct. 27 and Nov. 28, 2018, suffering foot, ankle and nasal fractures during various falls, DPH said. Following each fall, staff failed to implement appropriate interventions and failed to ensure the resident took precautions.
On Nov. 27, 2018, an LPN was seen cleaning a glucometer with an alcohol wipe after testing a resident’s blood sugar. The LPN knew the device should be cleaned with a manufacturer-approved wipe. But the LPN used the alcohol wipe because the approved wipe made the LPN nauseous, DPH said. An investigation found the LPN tested residents’ blood sugar approximately 30 times during that month without cleaning it properly.
Maefair Health Care Center in Trumbull was fined $6,960 after a resident suffered a broken right femur and needed surgery.
The resident, who required help from two staff and a Hoyer lift for transfers, tried to self-transfer on Sept. 3, 2019, after a nurse aide left to look for a lift and help. According to DPH, the aide should have used a call button to summon help instead of leaving the resident unattended.
“Maefair Health Care Center takes the care of its patients and residents very seriously,” said Tim Brown, spokesman for parent company Athena Health Care Systems. “We are confident that the issue raised in the report was isolated and not consistent with the care and customer service at our center. The staff member involved with this incident was re-educated on our policies regarding two-person assist care and the importance of following policies.”
Portland Care and Rehabilitation Centre Inc. was fined $9,060 after a resident choked on a pierogi while eating on May 16, 2019, according to DPH. The resident was taken to a hospital and treated for an onset of atrial fibrillation “perhaps incited by the stressful event of choking,” the citation said.
The resident, who was on a soft diet, required food cut into dime-sized pieces and supervised meals. But on that day, according to the citation, the resident was served an entire pierogi and tried to eat it whole.
New London Sub-Acute and Nursing in Waterford was fined $6,960 after a resident received the wrong medications and became unresponsive.
The resident was found unresponsive on Oct. 10, 2019, after an LPN administered the resident’s roommate’s medications to the resident by mistake, including the sedative Ativan, antidepressant Lexapro, and antipsychotic Clozapine, according to DPH. Emergency medical personnel took the resident to a hospital, where the resident was intubated and subsequently discharged Oct. 27 to a long-term care facility. The LPN who administered the medication was fired.
Apple Rehab Rocky Hill was fined $4,800 for three incidents in which residents left the facility.
On Oct. 12, 2019, a resident in a locked dementia unit left the building following an LPN who went outside to the parking lot. Staff returned the resident to the facility without injury.
On Nov. 15, 2019, a resident wearing a WanderGuard bracelet was found outside. The resident left through an unlocked door, and the alarm failed to sound.
On Sept. 22, 2019, a resident climbed out a window and fell, suffering a knee injury. According to the citation, the resident removed a window from its frame the day prior.
Officials at Apple Rehab West Haven, Regalcare at Southport, Portland Care and Rehabilitation Centre, New London Sub-Acute and Nursing, and Apple Rehab Rocky Hill didn’t return calls seeking comment.
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Montowese Health and Rehabilitation Center in North Haven was fined $1,320 after a nurse aide posted the video of the resident on Snapchat, DPH said.
On Aug. 29, 2019, a family member of the resident called the facility to complain about the video. In the video, the resident was seated in a wheelchair, wearing a white helmet and repeatedly asking for a grilled cheese sandwich. The video had been edited with the caption “All I want is a grilled cheese sandwich,” according to DPH.
When an administrator questioned the nurse aide about the video, the aide originally denied making and posting it, but later admitted to doing it. The aide had just attended training a day earlier in which staff were reminded that cell phone use is prohibited in resident care areas, the DPH citation said.
The aide no longer works at the facility and staff notified DPH and local police of the incident, according to facility spokesman Tim Brown.
The center “has a zero-tolerance policy for any type of abuse or neglect of its patients and residents,” Brown said. “The center maintains and expects its employees to follow multiple policies prohibiting the filming or photographing of its residents and patients.
“Since this incident occurred, the center has conducted multiple in-services with staff to re-educate them on existing policies, including the restriction of personal cell phone use in resident areas and to adhere to residents’ rights by not posting resident information to social media,” Brown said.
Water’s Edge Center for Health and Rehabilitation in Middletown was fined $6,960 after a quadriplegic resident fell out of bed and was injured while receiving care from a nurse aide.
On June 6, 2019, the resident, who was supposed to have the help of two staff members for bed mobility, fell off a bed onto the floor and suffered a broken femur when one nurse aide was changing a bed sheet, according to DPH.
Following the incident, staff were supervised as needed when assisting residents who need help with daily tasks and mobility, according to the citation.
Officials at Water’s Edge Center declined to comment.
Chelsea Place Care Center in Hartford was fined $1,500 after a resident with a history of alcohol and opioid dependence, as well as suicidal tendencies, was found dead several days after being discharged from the facility.
The resident was admitted to the facility for short-term rehabilitation on April 22, 2016, following a hospitalization for treatment of suicidal ideation and found to be “medically unstable,” the citation said. When the resident was discharged May 31, 2016, a transitional coordinator tasked with connecting the resident with post-discharge services wasn’t made aware of the discharge and had not finished ensuring mental health services were in place for the resident, DPH said.
According to the citation, the discharge plan didn’t ensure follow-up appointments were scheduled at a behavioral health facility, even though the resident had attempted suicide as recently as March 16, 2016.
After a home care agency was unable to contact the resident or make home visits after various attempts, the resident was found deceased on June 3, 2016. The cause of death was ruled as acute heroin toxicity associated with alcohol use, the citation said.
Though the incident happened in 2016, details were recently released in an “amended citation,” because Chelsea Place disputed the findings in the original citation, according to DPH.
“The health, safety and well-being of our resident community remain Chelsea Place Care Center’s utmost priority. This includes working to connect residents with adequate and necessary healthcare services after their discharge into the community whenever possible,” said spokesman David Skoczulek.
“In this particular case, we feel strongly that we fulfilled this duty. We respectfully disagree with DPH’s conclusion that a nursing home is legally responsible for the unforeseen actions of an individual after being safely and voluntarily discharged from the nursing home, which in this case included the collaboration and coordination through resources managed by the state of Connecticut through its Money Follows the Person program.”
]]>RegalCare at New Haven was fined $1,680 after four residents tested positive for cocaine.
On April 30, 2018, a resident tested positive for cocaine after being seen handing a dollar bill with white powder on it to another resident, according to DPH. A physician’s order dated May 3 implemented several interventions, including room searches every day for three days, but the resident’s room was only searched May 4 and May 5.
The resident who was handed the dollar bill with white powder on it, who had opioid dependence, tested positive for cocaine on May 1. Daily room searches were ordered for three days but, according to the citation, that resident’s room was only searched May 4 and May 6.
On May 12, 2018, another resident was found lying on a floor with a large hematoma and was unresponsive for two minutes, according to DPH. At a hospital, the resident tested positive for cocaine and opiates. A May 16 physician’s order called for the resident’s room to be searched daily for three days, but records failed to show the room was searched on May 17.
On May 18, 2018, the facility got a call from a methadone clinic saying another resident tested positive for cocaine, according to DPH. The resident said the cocaine was obtained from another resident, who had gotten it from a nurse aide. The nurse aide was fired.
St. Camillus Center in Stamford was fined $6,420 after a resident at risk for skin breakdown was found to have stage 2 and stage 3 pressure ulcers on the resident’s heels on May 30, according to DPH.
An investigation found the clinical record failed to show that physician treatment orders were obtained when the sores first were found, and there was no evidence that preventative measures were put in place prior to May 30. Physician’s orders dated five days later directed staff to clean the resident’s heels with saline and apply an ointment, according to DPH.
“St. Camillus Center is committed to providing high-quality care to our patients and residents,” said spokeswoman Lori Mayer. “Unfortunately, we did receive a citation from the Department of Public 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.”
Mystic Healthcare and Rehabilitation Center was fined $7,340 for several violations. A resident with psychosis and anxiety had 14 unwitnessed falls between March 2018 and January 2019, according to documents. In several of the falls, the resident sustained injuries, including: an arm skin tear and abrasion March 31, 2018; leg bruises July 13; and a left femur fracture that required surgery Jan. 16, 2019.
A resident developed a facility-acquired stage 2 pressure ulcer on the coccyx on Feb. 7, and an investigation found staff failed to take proper preventative measures. According to DPH, over the course of January and February, 43 shifts lacked documentation the resident had been repositioned and 28 shifts lacked documentation the resident was helped with mobility.
On Nov. 24, 2018 a resident’s leg got trapped under a Hoyer lift during a transfer. The nurse aides helping the resident didn’t report the incident to nursing staff because the resident seemed fine, but the resident suffered a broken left hip. The incident should have been reported, the citation said.
Officials at Mystic Health Care and RegalCare at New Haven did not return phone calls seeking comment.
]]>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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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.
]]>River Glen Health Care Center in Southbury was fined $10,000 for two instances in which staff failed to use wheelchair foot rests, injuring residents.
On July 22, 2018, a resident with dementia fell from a wheelchair while being moved by a licensed practical nurse. With feet down on the floor, the resident propelled forward from the chair, fell and suffered an injury to the forehead, according to DPH.
An investigation found foot rests should have been on the wheelchair but were not. According to the citation, the facility had no policy for leg or foot rest use, but the expectation was that they should have been used in this case. The resident was taken to a hospital and received three sutures for a forehead laceration.
On March 12, a nurse aide was pushing a resident in a wheelchair toward a shower room when, according to the nurse aide, the resident complained about the wheelchair cushion, leaned forward and fell face-first onto the floor. The resident was treated at a hospital for a forehead laceration and nasal bone fractures. The nurse aide said there were no foot rests on the wheelchair, according to the citation.
Officials at the facility didn’t return a call seeking comment.
Avery Heights, also known as Avery Nursing, in Hartford was fined $6,120 after a resident with dementia was injured in a fall.
The resident, who was identified as being at high risk for falls, fell onto a bathroom floor on Oct. 13, 2018. A nurse aide had helped the resident to the bathroom and told the resident to wait on the toilet while the aide got more towels, according to DPH.
When the nurse aide returned, the resident was getting up from the toilet and fell. According to the citation, the resident was taken to a hospital and treated for a broken right arm and a head laceration that required three staples.
Officials at the facility didn’t return a call seeking comment.
The Watermark at East Hill in Southbury was fined $6,120 after a resident suffered a broken femur in a fall.
A nurse aide was providing incontinence care to the resident, who had dementia and was a known fall risk, on March 15. The resident’s care plan called for two-staff assistance for bed mobility, but the nurse aide was providing care without help, according to DPH.
After removing floor mats on the side of the bed, and moving the bed to a higher position, the nurse aide turned away from the resident to get an incontinence pad from a cabinet, and the resident fell onto the floor, according to the citation.
The resident complained of left hip pain and was treated at a hospital for a broken left femur. According to DPH, the nurse aide should have had the resident’s bed on the lowest setting when providing care and should have gathered all needed supplies ahead of time.
“The safety and well-being of our residents is our top priority,” said Executive Director Jeffrey Williams. “At the time of the occurrence, we immediately self-reported the incident and performed an extensive internal investigation, which determined that the individual involved did not follow our training and protocol. That individual was terminated from his position as a CNA [certified nursing assistant ] and we utilized this opportunity to retrain our entire care team.”
For the next two months, a member of the nursing team observed delivery of care services to ensure the facilities protocol was understood and consistently followed, Williams said.
Greentree Manor Nursing & Rehabilitation Center in Waterford was fined $3,820 after a resident inappropriately touched two other residents and a 4-year-old visitor.
The resident—who had shown a pattern of sexual, inappropriate behaviors—was to be checked on by staff every 15 minutes and have one-on-one room supervision.
On Feb. 6, 2018, the same resident was accused of grabbing another resident’s breast, but no staff witnessed the incident. The accused resident was put on one-on-one supervision until the next day, when psychiatry staff recommended the supervision be downgraded to checks every 15 minutes, the citation said.
On Feb. 17, 2018, another resident reported seeing the same resident grab another resident’s groin on a couch outside the director of nursing’s office. Also that day a licensed practical nurse saw the resident near a nurse’s station reach an arm around a 4-year-old visitor and grab the child’s buttocks, according to DPH.
In all three cases, staff should have been monitoring the resident and redirecting the resident away from the other residents and the visitor, according to the citation.
Officials at the facility didn’t return a call seeking comment.
]]>The Springs at Watermark 3030 Park in Bridgeport was fined $6,960 after a resident fell onto the floor when being moved from a bed to a wheelchair by two nurse aides.
The resident suffered a broken right tibia and fibula in the fall, which happened May 4, 2018, according to DPH. An investigation found the nurse aides were using a Hoyer lift to help with the transfer, as outlined in the resident’s care plan, but the resident slid out of the lift pad. The pad was “bunched up” and had been incorrectly put above the resident’s head when it should have been placed at the base of the resident’s neck, according to the citation. Also, the wheelchair the resident was being moved into was incorrectly positioned.
Following the incident, the nurse aides were fired.
“The safety and well-being of our residents is our top priority,” said Kristin Butler, executive director and administrator. “At the time of the occurrence, we immediately self-reported the incident and performed an extensive internal investigation, which determined that the individuals did not follow our training and protocol, resulting in their termination. We retrained our entire care team and for three months following, a registered nurse was present at every Hoyer lift to ensure our protocol is followed, to ensure the safety and well-being of our residents.”
Harrington Court in Colchester was fined $6,120 after a resident received too much of a prescribed medication.
On Feb. 18, 2018, the resident, who had atrial fibrillation, had multiple wounds on the right lower leg that began excessively bleeding. Staff changing the resident’s dressing noticed an ace wrap, sock and shoe were soaked with blood and the resident was sent to an emergency room for evaluation, according to DPH.
An investigation found the resident had been given too much coumadin, a prescribed blood thinner, after a registered nurse transcribed a physician’s order incorrectly. According to the citation, the resident was supposed to get 2 milligrams of the medication daily Monday through Friday and 1.5 milligrams Saturday and Sunday, but instead was given 5 milligrams Monday through Friday.
“Harrington Court is committed to providing high-quality care to our patients and residents,” said spokeswoman Lori Mayer. “Unfortunately, we did receive a citation from the Department of Public Health in 2019 for an incident that happened in February 2018. 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.”
Seacrest Retirement Center in West Haven was fined $1,530 after an employee hit a resident in the face.
On Feb. 6, an employee reported to a care coordinator that a resident had swollen right eye. According to DPH, the resident said that the employee who reported the swollen eye injury caused the injury. The employee later admitted to hitting the resident in face with an open hand; the resident was taken to a hospital and treated for a right eye orbit fracture.
The employee said the resident became combative while receiving incontinence care and started hitting the employee in the face with a closed fist, according to the citation. The employee hit the resident back, with an open hand, but originally denied doing so out of fear of getting in trouble.
Following the incident, the employee was fired and staff were educated on how to deal with residents’ aggressive and agitated behaviors, according to DPH.
“Seacrest take the care and safety of our residents very seriously,” said owner Lewis Bower. “The employee involved was removed from the facility immediately once the incident was reported, and then was terminated.”
West River Rehab Center in Milford was fined $1,160 after a resident removed a WanderGuard bracelet and left the facility. The resident indicated to staff the desire to see a family member, but left the facility without being signed out by family. The resident was found, returned to the facility and placed on one-to-one supervision, the citation said.
Officials at West River did not return a call seeking comment.
]]>Westport Rehabilitation Complex was fined $8,120 following the discovery of the thefts and another incident in which a resident was injured. An investigation found that 20 residents had money missing from their resident trust funds and a facility business office manager was responsible, according to the Department of Public Health (DPH). In total, $3,161 was taken from the residents’ accounts.
According to the citation, the missing funds were discovered in November 2018 when an employee alerted the facility’s administrator of “concerns regarding the facility-managed residents’ trust funds.” Several withdrawal documents appeared to have been altered with Wite-Out. The business manager who misappropriated the funds was terminated on Nov. 29, but the administrator didn’t report the incident to DPH until Dec. 6, the citation said.
Also at Westport, a resident suffered a right femur fracture after falling off a bed while receiving care on Oct. 1, 2018. A nurse aide knew the resident’s care plan called for two-staff assistance but tried to provide incontinence care alone when no other staff were available. The resident fell and was treated at an emergency department.
Officials at the facility didn’t return a call seeking comment.
Glen Hill Center in Danbury was fined $6,960 after a resident was mistakenly given two doses of insulin on the same day. The resident was found in the early morning of Dec. 6, 2018, unresponsive, diaphoretic, cool to the touch, and with low blood sugar, according to DPH. The resident was given a dose of glucagon and orange juice and responded well.
An investigation found the resident was given a dose of long-acting insulin the morning of Dec. 5 and a physician subsequently ordered a new, different dose starting at night. A licensed practical nurse transcribed the order incorrectly.
Officials at the facility didn’t return a call seeking comment.
Beechwood in New London was fined $6,120 after a resident fell from a wheelchair and suffered a head laceration. The resident, who had dementia and was at risk for falling, fell forward out of a wheelchair on Aug. 11, 2018, while being transported by a nurse aide, according to DPH.
The resident was taken to an emergency department and received two sutures.
The incident happened after a nurse aide transported a resident in a wheelchair but did not use leg rests as required. The facility didn’t have a wheelchair policy that directed the use of leg rests on wheelchairs, DPH said.
“Beechwood is proud of its family-owned and -operated history since 1955 and its repeated and current five-star ranking with Medicare. Our long record of excellence is not without isolated issues, such as this one,” said Bill White, president and administrator. “It was investigated, assessed, and corrected immediately and, as in all service recoveries, we are made wiser through learning and correction.”
Carolton Chronic & Convalescent Hospital in Fairfield was fined $3,060 after a resident fell out of a chair while being improperly transported to a shower.
The resident fell and suffered a forehead laceration on Jan. 1, while being moved in a shower chair by a nurse aide, according to DPH. The resident required the assistance of two staff members to get to the shower room, but the nurse aide tried to transport the resident without help, according to the citation. The resident also should have been in a shower trolley, not a shower chair. A registered nurse told investigators that, while it wasn’t noted in the clinical record, the resident received 10 sutures at a hospital to close the head laceration.
Officials at the facility didn’t return a call seeking comment.
Touchpoints at Manchester was fined $1,530 after a resident required two toe amputations and a transfemoral (above-the-knee) amputation.
The resident, who suffered from diabetes and other diagnoses, was taken to a hospital on Aug. 22, 2017, with necrotic, black wounds on the right and left big toes, according to DPH. Following an MRI on Aug. 31, the resident underwent two great toe amputations on Sept. 1 and a right transfemoral amputation on Oct. 20.
The state said that facility staff made multiple errors in assessing the toe wounds the resident developed prior to hospitalization. Among them, according to the citation: documentation failed to show that an advanced practice nurse had conducted a physical examination of the bilateral toes on Aug. 10; staff reported inflammation near toenails on Aug. 15 but failed to identify that a podiatry consult was ordered or that open-toed shoes or other alternatives were implemented; in July and August, physicians’ records failed to include orders for diabetic foot monitoring; and skin audits conducted in June were unavailable.
“Touchpoints at Manchester takes clinical care concerns very seriously,” said David Skoczulek, vice president of business development for parent company iCare Health Network.
“The Touchpoints at Manchester leadership team extensively reviewed this case with nursing leadership from the care center and developed a specific quality assurance and clinical documentation plan.”
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