Tracing path of virus at nursing home
A sick nurse, quarantine failures allegedly sparked deadly outbreak at Three Rivers
On July 23, the results of coronavirus testing on the 60 or so residents at the Three Rivers Healthcare Center in Norwich came back. All negative. The nursing home had been spared the devastation that had torn through other facilities in Connecticut, with few COVID-19 cases and no deaths.
The next day, Mary A. Ciezynski returned to work at Three Rivers after a family vacation at the Rhode Island shore.
According to state inspection records, two family members the nurse had vacationed with were awaiting test results for the coronavirus, and Ciezynski told co-workers she wasn’t feeling well. But she came to work anyway. As she prepared to work a double shift, she first paid a visit to her mother — who was a patient at the facility, according to records and interviews with sources.
The facilities nursing director later recalled that she had to remind Ciezynski repeatedly to wear a mask and properly socially distance during that visit — one of a series of problems at Three Rivers outlined by public health officials.
From Ciezynski showing up to work, to allegedly not wearing a mask, to infection control lapses at the facility and to a subsequent exposure incident at nearby Backus Hospital, the trail of COVID-19 at Three Rivers involved a series of missteps and errors, investigators say.
Many — if not most — of the missteps were either preventable or violations of basic procedures that have become standard in Connecticut over the six months the state has been battling the spread of the deadly coronavirus, according to state officials, inspection reports and interviews with experts.
So far the outbreak has left as many as three dead and some three dozen infected — including Ciezynski’s mother. Another resident of Three Rivers — Gloria Trombley died last week of dementia and COVID-19.
“We are looking at all of our options to hold individuals responsible for their action,” Long-term
care ombudsman Mairead Painter said in an interview with The Courant about the situation at Three Rivers. “I do feel that this clearly rises to the level of an elderly abuse issue.”
Public reports on the Three Rivers outbreak didn’t name Ciezynski, known as RN#2 in state Department of Public Health documents, or spell out the relationship between her and her mother — called “Patient 22” in investigative documents.
But The Courant, based on sources close to the investigation and at the nursing home, is naming the nurse and outlining in detail an episode that has shocked public health experts. Several attempts have been made to reach Ciezynski for comment.
‘Sinus issues’
When her shift started on July 24, Ciezynski told a colleague she hadn’t been feeling very well since returning from a beach vacation with her family, reports said. She was having “sinus issues” and two peopled she’d vacationed with were already waiting for test results.
A fellow nurse asked her to move away, state inspection reports say. That nurse — called LPN#1 in the DPH report — was the second staff member to test positive for the virus a few days later.
The first was Ciezynski, who found out on July 27 she had COVID-19 — one day after her family members she had vacationed with were told they had the virus as well.
Among those sickened at Three Rivers was Mary Suleske, Ciezynski’s mother. She died a few weeks later.
While Suleske was considered a COVID-19 positive case under DPH guidelines and their summary of the impact, she didn’t die from the virus. The Chief State Medical Examiner’s office after reviewing the death again following inqui
ries from The Courant has concluded she died of sepsis.
“DPH reports COVID-associated deaths, which means any death that tests positive for COVID, regardless as to whether COVID caused or contributed to the death, will be tracked by them as a COVID-associated death,” Chief State’s Medical Examiner James Gill said. “Death certification is a different matter.”
The state’s long-term care ombudsman, Mairead Painter, while not naming Ciezynski, has called for a possible criminal investigation for recklessly endangering the lives of the nursing home residents. She also has called for a review of her nurse’s license.
Ciezynski has been a registered nurse since 1981 and has no complaints or actions against her license, state records show.
Several employees told DPH investigators that they saw Ciezynski not wearing a mask during her double shift on July 24. None of them questioned her about it because she was their boss.
“It’s common sense for everyone in our state, country and world if you don’t feel well stay home, but that just didn’t happen here,” Gov. Ned Lamont’s Chief Operating Officer Josh Geballe said at a recent press conference.
“You need to stay home, and you need to protect your community. That did not happen here.”
Protocol not followed
The investigation of the nursing home resulted in the state issuing a “statement of deficiency,” citing the nursing home for a range of infection control deficiencies, including failure to properly use PPE and failure to properly quarantine an exposed resident.
There was insufficient staff at times, the report said, to designate staffers to work exclusively with patients who tested positive for COVID-19.
At a recent press conference, Lamont said: “Lots of protocols weren’t followed” in the Norwich case “but that doesn’t mean those protocols weren’t in place and those rules weren’t in place already.”
The first positive COVID19 case involving a patient was on Aug. 2, when Backus informed them a resident who had been taken to the hospital had tested positive. The first death of a Three Rivers resident was Robert Dennis, who died on Aug. 14, according to the state medical examiner’s records. His cause of death included acute encephalopathy, hypoxic respiratory failure and COVID-19, records show.
One of the issues identified by state officials was a failure to separate COVID positive cases from COVID negative ones. The nursing home didn’t do so until DPH investigators showed up on
Aug. 17 — even though they were aware that three days earlier a Three Rivers resident had died of COVID19 at Backus Hospital, the reports says.
Another problem identified by investigators was staffing. The facility was so short-staffed that nurses cared for both COVID-19 positive and negative residents at the same time. At one point there was one nurse tending to 20 people, the health department says.
There also was a lack of PPE as employees reused surgical gowns and masks. The shortage was so dire that union officials brought PPE to the facility because of concerns for the safety of their members working there.
There also were issues with how the facility was tracking its employees coming into work. Under state guidelines, they are supposed to fill out forms indicating their current health status and whether they have been out of state since last working. They are supposed to have their temperature taken at the beginning and end of each shift.
DPH investigators found that the facility’s screening document for staff “did not include an out of state travel question” and that the forms hadn’t been updated since June 17. Administrators admitted they had no idea that Ciezynski had traveled out of state until after she tested positive for COVID.
“The directives from the state are all very clear. They just didn’t do what they were supposed to do for some reason,” Painter said. “They didn’t follow the protocols, and we expect them to be held accountable.”
DPH is still investigating the outbreak, and state action in the case could be announced in the next few days. A spokesman for JACC Health Center of Norwich, which operates Three Rivers Health Care, said Friday that the supervisory nurse is no longer an employee at Three Rivers. She was a part-time employee who hasn’t worked since July 24.
The spokesman confirmed there have been 22 residents who have tested positive and six staff members. The state attributes three deaths to the outbreak; Suleske, whose official cause of death was sepsis, not COVID-19, also died amid the outbreak.
In a previous statement, Scott Ziskin, president and CEO of JACC Health Center of Norwich, said that infection control policies and procedures in place kept the facility free of COVID-19 for four months.
“Since the occurrence of positive COVID-19 cases reported in our home, we have been working with the state Department Public Health (DPH) and its epidemiologists as we monitor the health of our residents and staff,” he said. “This week, we submitted a comprehensive plan for corrective action to DPH, and we continue to work with DPH on a daily basis to implement the plan as the situation evolves.”
Hospital spread
As with many episodes involving the virulent and highly contagious virus, the outbreak spread.
One of the first residents from the nursing home to get the virus was transported to nearby William Backus Hospital, where that patient is suspected of being at the root of an incident that led to COVID-19 infections in at least nine hospital staff.
Dr. Ajay Kumar, chief clinical officer for Hartford HealthCare, which owns Backus, said that a patient from the nursing home tested negative for COVID19 when brought to the hospital. As the patient was preparing to return to the nursing home, however, the patient tested positive.
With a negative test on arrival at Backus, the patient was not taken to the hospital’s COVID - only unit but instead to an area known as E-3. Kumar said all infected employees worked on the same floor. He said the hospital has tested 68 employees since they became aware of the outbreak. The other patients who were on the floor at the same time as the Three Rivers patient in question have been tested for the virus and were negative, he said.
Kumar said even though the patient wasn’t initially assigned to the COVID floor, that “it was a lapse in wearing proper PPE by an employee that led to the spread.”
DPH is still investigating the outbreak at Backus as well, DPH spokesman Av Harris said.
Hartford Hospital spokeswoman Tina Verona said nine Backus employees who are connected with the incident at Backus have tested positive for COVID-19. Two other employees, who are not connected to that incident, also tested positive.
“Backus Hospital continues to work closely with the Department of Public Health regarding this incident,” Verona said.
Among the Backus employees who tested positive was Shanon Pereira, a nurse who worked on E-3 but said she didn’t directly care for the Three Rivers patient.
Pereira said she was angry hospital officials appeared to be blaming the outbreak on an employee not properly wearing PPE rather than looking at how the patient ended up on that floor in the first place. Pereira said she is religious about wearing her mask for health reasons.
The “exposure to the virus wasn’t contained,” she said. Both of her parents have tested positive for COVID19, and her son, who is not quite 2 years old, also is now positive. “It’s very upsetting to hear everyone say it’s an isolated incident — because it’s not,” Pereira said.
Pereira said Friday she met with DPH investigators last week.
“I’ve been very careful. Every time I came home, I took all of my hospital clothes off in the garage and showered immediately,” Pereira said. “But this is a highly contagious virus. Once you develop symptoms, it’s too late. You’ve already spread the disease.”