Report: 2 dead from lapses in care at CT nursing homes
Six nursing homes have been cited by the state Department of Public Health for lapses in care, including two cases in which residents died.
DPH fined Hancock Hall in Danbury $10,000 in August in connection with three incidents, including the case of a resident who died in June from complications due to a head injury caused by a fall out of a lift, the state citation said.
Four days before the death, the resident was kicking and punching two nurse’s aides who were moving the person in the lift, the citation said. A clip on the lift pad came undone and the resident slipped out of the sling and onto the floor and sustained a head injury. A review found that the aides should have stopped the lift and notified a nurse when the person became combative. The citation said the aides also used the wrong-sized lift pad.
The fine also covered an incident in January 2018 in which a resident broke a bone in the back after falling out of a recliner, the citation said. The citation said the home did not conduct a thorough investigation of the fall.
The third case involved a resident who was given an overdose of insulin in May and was hospitalized with tremors, weakness, a headache and low blood sugar, the citation said. The resident recovered. A registered nurse who administered the overdose did so because he did not carefully check the insulin label against medical records, the citation said.
Jennifer Malone-Seixas, the administrator at Hancock Hall, said she was unable to comment on the citation due to privacy concerns but wrote, “Hancock Hall remains committed to providing the highest quality care for our residents.”
Branford Hills Health Care Center was fined $3,000 in October 2017 in connection with a September 2017 incident in which nurses failed to initiate CPR promptly when a resident with schizophrenia and depression was found unresponsive. The resident’s head was covered with a plastic bag, the DPH citation shows.
The citation said a licensed practical nurse and an RN failed to initiate CPR immediately. The LPN said that she didn’t know if she should touch the resident because it was an apparent suicide, and the RN directed the other nurse to start CPR only after calling 911 and a supervisor, the citation said.
Janet Woxland, the administrator at Branford Hills, said the home was saddened by the resident’s death and places a high priority on safety, but it disputes DPH’s findings.
“The facility asserts that this was an unavoidable event, and we disagree with the state’s findings,” she wrote. “The resident’s sister visited our facility and thanked the staff for the love and individualized care that the resident was given over the past seven years.”
Greentree Manor Nursing and Rehabilitation Center in Waterford was fined $9,660 in August in connection with its handling of a resident in July who repeatedly made suicidal comments, a DPH citation said.
The resident was not harmed, but the citation said the home did not begin checking the resident every 15 minutes until two days after a doctor had ordered the staff to do so. The citation also said a knife was left in front of the resident in a dining room, where a nurse’s aide failed to closely watch the resident, as ordered. An RN wrote in a note that she had notified a supervisor about the resident’s suicidal comments immediately but actually didn’t tell the supervisor for nearly two hours, the citation said.
Ted Vinci, Greentree’s administrator, said he could not comment on the incident due to resident confidentiality. He added that the facility was found by DPH to be in “substantial compliance” with state regulations.
The state fined Apple Rehab Watertown $3,060 in June in connection with a January 2018 fall in which a quadriplegic resident sustained a skull fracture, a DPH citation said.
A nurse’s aide was transferring the resident into a wheelchair when the person’s legs spasmed and the wheelchair tipped over backwards, the citation said. The resident fell to the floor and was hospitalized in intensive care with a head injury, the citation said. The nurse’s aide said she should have had another staff member help her move the resident, the citation said.
After the incident, the staff was retrained and required to sign off that they understand the home’s policies, John Anantharaj, the vice president for clinical services at Apple Rehab, said.
“Apple Rehab prides itself on providing individualized care to our loved ones,” he said. “An immediate education [was held] for staff to further excel the quality of care, correct the DPH findings and prevent future occurrences.”
In August, the Bridgeport Health Care Center was cited in connection with a resident with diabetes who was hospitalized in October of 2017 with sepsis, high levels of potassium in the blood and renal failure, the citation said.
An RN could not provide documentation that showed that the resident’s hydration levels had been assessed in the month before the resident’s hospitalization, the citation said. The home was fined $1. DPH spokeswoman Elizabeth Conklin said the agency imposes a $1 fine when a facility is in receivership.
The home’s administrator did not respond to requests for comment.
In August, DPH also cited Rosegarden Health & Rehabilitation Center in Waterbury because several residents were seen without identification bracelets on their wrists, as is required, so that nurses can check IDs before giving out medication, the citation said. Three residents told state inspectors that they weren’t given ID bracelets or had gone without them for some time, the citation said. The home was fined $1. Rosegarden Health closed in October, Conklin said.
This story was reported under a partnership with the Connecticut Health I-Team, a nonprofit news organization dedicated to health reporting.