First, she didn’t die from virus, then she did
Resident’s death sheds new light on Norwich nursing home’s issues
Nina Grabowski died alone in her sleep sometime after 4 a.m. on Aug. 29, a death initially attributed to dementia and respiratory failure.
Officials at the embattled Three Rivers Nursing Home failed to notify the medical examiner’s office of her death — even though the 93-year-old woman had tested positive for the coronavirus nearly two weeks earlier. The home, according to records, also failed to include written documentation she was COVID positive when they sent her to a hospital twice, days before she died.
But, as it turned out, coronavirus did kill Nina Grabowski.
After The Courant raised questions about the case with state officials, Chief State Medical Examiner James Gill reviewed the death certificate and changed it to indicate that COVID-19 was the primary cause of death. Dementia is now listed as a secondary cause.
Three Rivers’ handling of Grabowski’s final days — and her death — appear to have violated COVID-19 protocols that had been established months ago as the virus swept through nursing homes across the state, killing upward of 2,500, according to state records and interviews with people familiar with the case.
The facility failed to notify Backus Hospital in her records she was a COVID patient when she was transported there and failed to report her death to the medical examiner. Under an executive order issued by DPH in late March, all nursing homes were required to report possible COVID related deaths to the state medical examiner’s office and to DPH.
“As the death certificate was written, it was not a reportable death,” Gill said. “But clinicians
must report known or suspected COVID-19 deaths to the OCME and DPH.”
State inspection records also point to a number of problems in the records concerning her treatment at Three Rivers.
Outbreak
Grabowski is one of at least three residents of the facility to die of COVID since an outbreak that began in late July. DPH has issued two investigative reports detailing numerous violations at Three Rivers, covering violations of infection control standards including failure to properly use PPE, failure to properly quarantine an exposed resident and concerns over staffing levels.
The situation prompted the state to appoint a temporary manager, who within days suggested all the residents needed to be removed from the facility.
On Sept. 16, the state took the unprecedented step of issuing an emergency order to remove all 53 patients remaining at Three Rivers. The 17 residents with COVID are being transferred to a nursing home in East Hartford, while state officials are racing to find placements for the 29 residents who have remained COVID negative.
They have told families they hope to have everyone placed in new homes within two weeks.
The outbreak at Three Rivers began in late July. State records detail a widely-publicized situation involving a supervising nurse who came to work not feeling well and knowing that two family members with whom she had been on vacation were awaiting COVID19 tests. Several employees told DPH investigators that the nurse didn’t wear her mask all of the time during a double shift.
Since then, there have been 21 residents who have tested positive, along with six staff members, and at least three deaths, including Grabowski. In addition, the
virus spread to Backus Hospital and infected at least nine workers there when a resident of Three Rivers was transferred there.
Resident No. 10
Among those caught in the outbreak was Graboskwi, a 93-year-old woman who appeared to have no family involved in her care. Grabowski’s death certificate does not list any next of kin, so it is unclear if she has any family. Her husband died in 1985 and her son in 2017.
Grabowski’s death at Three Rivers was cited in recent state Department of Public Health reports, which outlined the depth of the problems at the facility.
Grabowski was referred to as “resident #10” in DPH reports, but The Courant was able to obtain her death certificate based on when DPH officials said the resident had died and her time of death. The initial death certificate, certified by a nurse at Three Rivers, said the primary cause of death was dementia and listed respiratory failure among the secondary causes.
There is no mention of the fact she had COVID — even though nursing home officials knew she had tested positive on Aug. 17, according to a DPH review of her medical records included in the agency’s 71-page report.
Grabowski was taken to the hospital twice between Aug. 17 and Aug. 19, records show. The first time it was because her feeding tube had dislodged, according to DPH records. The second time was because she had a cough, chest congestion and a fever over 100 degrees. Grabowski was taken to the emergency room and diagnosed with pneumonia, given an antibiotic and sent back to Three Rivers the same day, records show.
In its report, DPH cites Three Rivers for failing to inform in writing “another acute care facility” that Grabowski had COVID. The report doesn’t mention the hospital by name, but it likely refers to nearby Backus Hospital.
Details of Graboski’s treatment at the hospital, including whether Backus did its own COVID testing, remain unclear. Tina Verona, a spokeswoman for Hartford Healthcare, which owns Backus, said that “HIPAA regulations preclude us from sharing any specifics about a patient without express consent.”
But, she added, “Backus Hospital currently treats any patient transferred from a nursing home as COVID positive.”
Grabowski lived another week at Three Rivers, during which time state health officials identified a number of issues.
Records show a doctor prescribed morphine for her and last checked on her on Aug. 25 when he noted it still sounded like she had pneumonia in her left lung. DPH investigators noted the last nurse’s report for Grabowski was on Aug. 22, even though there are supposed to be daily reports.
Since she was in the COVID wing, she was on four-hour checks of her vital signs. But even with those records, DPH found discrepancies reporting that on Aug. 28 there were two sets of records, called flowsheets, for her vitals with different numbers, particularly for her oxygen — a key metric when evaluating patients with breathing problems.
The last time a nurse checked on Grabowski was 4 a.m., records show.
When a nurse went into her room at 8:38, Grabowski had died.