Masonicare Health Center in Wallingford was fined $3,900 after a resident developed a severe pressure ulcer.

On June 12, 2017, a resident who suffered incontinence and was a risk for skin breakdown was diagnosed with an unstageable deep tissue injury in the lower back. An advanced practice registered nurse determined the resident had the wrong type of mattress and recommended the use of a pressure-reducing cushion, according to DPH.

Once the resident received the cushion, it was under-inflated on multiple occasions and documentation from May through August failed to show staff were monitoring its inflation, according to the citation.

Margaret Steeves, vice president of marketing and communications at Masonicare, said patient safety is the facility’s top priority.

“Regarding this particular incident, Masonicare conducted an extensive review of practice and care delivered,” she said. “While we disagree with the findings, we will comply with the fine.”

Arden House in Hamden was fined $3,660 for four incidents in which residents were harmed.

On May 8, 2017, a resident suffered a hematoma on the left arm after a nurse aide pulled a call bell away from the resident, according to DPH. The resident hit the call button due to difficulty breathing. When the nurse aide tried to calm the resident, the resident began swinging the call bell, which led to the injury. The nurse aide was fired following an investigation, DPH said.

Another resident suffered a stage two pressure ulcer, which healed and then re-opened, according to DPH. The initial wound was diagnosed on Feb. 2, 2017, healed by Feb. 17, then later reappeared and worsened. Staff failed to notify other staff and the resident’s family when the wound worsened, according to the citation.

On May 22, 2017 a resident who required two-staff assistance for mobility fell to the floor after trying to stand up from a wheelchair without help, according to DPH. The resident was bleeding from the mouth and taken to an emergency department for evaluation.

On March 16, 2017, a resident was admitted to a local hospital with twitching, hypothermia, hypotension and septic shock due to multifocal pneumonia, according to DPH. An investigation found the resident’s fluid intake and output weren’t monitored from March 9 to March 16.

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

The Mary Wade Home in New Haven was fined $3,060 after a resident fell out of bed and suffered a femur fracture.

On June 1, 2017, one nurse aide was providing morning care to the resident, who required two-staff assistance for all care, and was rolling the resident over to the opposite side of the bed when the resident fell to the floor, according to DPH.

The resident was taken to a hospital and diagnosed with a right femur fracture. After being readmitted to the facility on June 2, it was discovered on June 9 that an immobilizer provided by the hospital was not on the resident properly, according to the citation.

“Following an incident which resulted in the injury of a resident last June, we took immediate disciplinary and corrective action to prevent any similar incident from occurring,” administrator Stanley DeCosta Jr. said. “Our entire staff was re-educated and trained on proper procedures for this type of resident care. The resident affected is fully recovered and continues to reside with us at Mary Wade Home.”

Chestelm Health & Rehabilitation Center in East Haddam was fined $3,060 after a resident was hurt in a fall.

On Sept. 15, 2017, a resident with severe cognitive impairment, who was required to have staff nearby when using the bathroom, fell while left unattended, according to DPH.

X-rays at the facility of the hips and pelvic area showed no fractures, but the resident was taken to a hospital three days later and x-rays there revealed several rib fractures and a hemothorax, or collection of blood in between the chest wall and the lung, according to the citation.

An investigation found the nurse aide left the resident alone to answer other residents’ call bells, according to DPH.

“There are times split decisions have to be made when caring for multiple residents,” administrator Brenda Marinan said. “Our staff are very dedicated, loving and compassionate people who were also upset over the resident injury. We support our staff and residents like family members. The resident has recovered and is happily residing with us.”

Rose Haven Ltd. in Litchfield was fined $3,000 after a resident suffered a skin tear on the back while being moved incorrectly by a nurse aide.

On April 9, 2017, one nurse aide tried to move the resident from a wheelchair to a recliner chair manually, despite a physician’s order that the resident required the help of two staff and a mechanical stand lift for all transfers, DPH said. The nurse aide didn’t know the resident required the help of two staff and was reassigned to another facility unit.

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

Douglas Manor in Windham was fined $1 after a resident, who was supposed to be checked for incontinence every two hours, was inadvertently left on a bedpan for five hours on Oct. 13, 2017.  The $1 fine is because the facility is in receivership, DPH said.

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

Avon Health Center was fined $1,090 on Sept. 16, 2014 in connection with two residents who fell. On March 14, 2014, a resident fell out of a mechanical lift when a clip holding a sling broke. The person was hospitalized, found to have broken a bone at the base of the skull and died six days after the fall, the DPH citation states. After the incident, the staff was re-trained in the use of mechanical lifts.

The citation states that another resident broke a wrist during a fall March 25, 2014 and the home found that a nurse’s aide should not have left the person alone.

While the home disagrees with some of the state’s findings, it is barred from discussing the incidents by state and federal privacy laws, administrator Tina L. Richardson said.

“Avon Health Center, a five-star facility, is committed to providing quality care and services to all of our residents,” she said. “We regularly assess our practices, policies and procedures as part of our on-going effort to make improvements to the care we provide to all our residents.”

On Oct. 19, Countryside Manor of Bristol was fined $1,020 in connection with a resident’s death. The resident had been admitted in September following a pulmonary embolism and was placed on two anti-coagulant drugs.

The resident remained on both drugs until Oct. 3 when hospitalized for pain and multiple bruises. The resident was sent for emergency surgery and died Oct. 7. A doctor later said a nurse should have reported to the doctor Sept. 29 that the person was still on both drugs, the citation said.

Countryside’s administrator could not be reached for comment.

In two Sept. 19 citations, Watrous Nursing Center in Madison was fined $1,510 and $1,370 involving residents who fell multiple times.

DPH said one resident fell eight times between March 4 and May 12, when the person struck his or her head on a chair. The resident was medicated for pain and hospitalized May 22 and diagnosed with a broken neck bone, the DPH citation said. DPH said the home failed to notify a doctor about the neck pain for five days.

The home was also fined in connection with the same resident being hospitalized for acute kidney injury and dehydration. The home failed to monitor the resident’s bowel movements, DPH found.

The home was also cited in connection with a resident who broke the same hip twice and had 22 falls between March 12 and Aug. 10, DPH said.

In that case and the case of a resident who fell 34 times between Feb. 25 and July 10, DPH found that the home’s interventions to prevent falls were not effective. That resident broke a hand bone and had two head injuries due to falls, DPH said.

“As with all residents, individual care plans and associated interventions were in place and policies and procedure[s] regarding these interventions were reviewed with all staff,” said Ann Collette, a spokeswoman for Apple Rehab, which owns Watrous.

On Aug. 4, Cambridge Health and Rehabilitation Center in Fairfield was fined $1,090 in connection with a resident who sustained a cut that needed 11 stitches to close after being transferred from a wheelchair to a bed. The citation said a nurse’s aide failed to use protective legwear when moving the resident.

Cambridge Health’s administrator could not be reached for comment.

The Mary Wade Home in New Haven was fined $1,020 on Sept. 15 in connection with a resident whose pressure ulcer deteriorated to a deep tissue injury by July 15. The home’s records did not reflect that the staff had followed a wound specialist’s advice, DPH said.

Administrator Andrew Tarutis said the staff works hard to provide quality care for its 140 residents, adding that “corrective action and procedures were incorporated to address this isolated incident and prevent any future concerns. The Mary Wade Home strives for excellent clinical outcomes, consistent with our five-star rating by the federal government, and we are pleased to report that the resident involved has completely healed as a result of the care received.”

On March 27, Grove Manor Nursing Home in Waterbury was fined $220 in connection with a resident who left the home with a visitor Oct. 26, 2014, went to an apartment and rode back to the nursing home with the police. The DPH citation said the home failed to implement changes after the resident left the home without permission.

Grove Manor’s administrator could not be reached for comment.