6 nurs­ing homes fined for care lapses

New Haven Register (New Haven, CT) - - KICKOFF - By Cara Ros­ner Cara Ros­ner is a Conn. Health I-Team Writer. This story was re­ported un­der a part­ner­ship with the Con­necti­cut Health I-Team (www.c-hit.org).

Six Con­necti­cut nurs­ing homes have been cited and fined by the state Depart­ment of Pub­lic Health for vi­o­la­tions, in­clud­ing one in­stance in which a res­i­dent died af­ter a se­ries of staff er­rors.

St. Camil­lus Cen­ter in Stam­ford was fined $6,000 af­ter a res­i­dent died and video footage at the fa­cil­ity sub­se­quently showed staff waited 10 min­utes to ad­min­is­ter CPR af­ter find­ing the res­i­dent un­re­spon­sive.

On Feb. 16, 2018, a res­i­dent with lung can­cer was found sit­ting on the floor. A nurse aide found the res­i­dent un­re­spon­sive, not breath­ing and with no pulse, ac­cord­ing to DPH.

Video footage showed staff had not opened the door to the res­i­dent’s room or checked on the res­i­dent be­tween 6:26 p.m. on Feb. 15 and 5:19 a.m. on Feb. 16. Also, staff did not be­gin CPR on the res­i­dent un­til 10 min­utes af­ter the res­i­dent was ob­served by a li­censed prac­ti­cal nurse to have no pulse, DPH said.

The res­i­dent was taken to a hospi­tal and later pro­nounced dead. A reg­is­tered nurse, li­censed prac­ti­cal nurse and nurse aide sub­se­quently were ter­mi­nated, DPH said.

“St. Camil­lus Cen­ter is com­mit­ted to pro­vid­ing high-qual­ity care to our pa­tients and res­i­dents. Since (the ci­ta­tion), we have pro­vided ad­di­tional staff ed­u­ca­tion and train­ing, and sub­mit­ted a plan of correction to the state,” said spokes­woman Lori Mayer. “At this time, we are in full com­pli­ance with state and fed­eral reg­u­la­tions.”

River Glen Health Care Cen­ter in South­bury was fined $3,470 for two in­ci­dents.

On Oct. 31, 2017, a res­i­dent suf­fered a fe­mur frac­ture af­ter fall­ing. The res­i­dent was walk­ing with the help of a nurse aide and tripped. An in­ves­ti­ga­tion found the nurse aide wasn’t us­ing a rolling walker, as re­quired un­der the res­i­dent’s care plan, and didn’t use a gait belt on the res­i­dent, ac­cord­ing to the DPH ci­ta­tion.

On May 30, 2017, a res­i­dent with hy­per­ten­sion and atrial fib­ril­la­tion was sent to the hospi­tal af­ter re­ceiv­ing an in­cor­rect dosage of a blood pres­surelow­er­ing med­i­ca­tion. Be­tween May 25 and May 30, the res­i­dent was given 37.5 mil­ligrams of the med­i­ca­tion when only one-third of a tablet, or 12.5 mil­ligrams every 12 hours, was to be ad­min­is­tered, the ci­ta­tion said.

A nurse aide made a tran­scrib­ing er­ror that re­sulted in the wrong dosage. The res­i­dent be­came dizzy and nau­seous, ex­hib­ited a slower-than-nor­mal heart rate and had low blood pres­sure as a re­sult, ac­cord­ing to the ci­ta­tion.

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

Saint John Paul II Cen­ter in Dan­bury was fined $3,270 af­ter a res­i­dent broke an arm in a fall.

On Aug. 15, 2017, a res­i­dent suf­fered a head in­jury af­ter fall­ing, the ci­ta­tion said. A nurse aide was mov­ing the res­i­dent when the in­ci­dent oc­curred. The nurse aide didn’t use a gait belt when mov­ing the res­i­dent, as re­quired by pol­icy, ac­cord­ing to DPH. In­ves­ti­ga­tors also found the res­i­dent had re­cently be­come weaker and needed the help of two staff for transfers, but the res­i­dent’s care plan had not been up­dated with the change.

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

Aaron Manor in Ch­ester was fined $3,060 af­ter a res­i­dent was in­jured in a fall.

The res­i­dent’s care plan called for two-per­son as­sis­tance with a sit-to-stand lift for all transfers, but on

Dec. 16, 2017, the res­i­dent fell to the floor when be­ing helped by one nurse aide, ac­cord­ing to DPH. The res­i­dent was ad­mit­ted to a hospi­tal and un­der­went surgery to re­pair a bro­ken fe­mur.

The nurse aide was aware the res­i­dent re­quired two-staff as­sis­tance but tried to move the res­i­dent alone be­cause no other staff was avail­able to help, ac­cord­ing to the ci­ta­tion.

Ad­min­is­tra­tor Deborah Bradley de­clined to com­ment.

Vil­lage Crest Cen­ter for Health & Re­ha­bil­i­ta­tion in New Mil­ford was fined $3,060 af­ter a res­i­dent was in­jured fall­ing from a wheel­chair that a nurse aide was push­ing.

On Oct. 15, 2017, the res­i­dent suf­fered a fore­head lac­er­a­tion that re­quired six su­tures at a hospi­tal. Ac­cord­ing to the ci­ta­tion, the nurse aide was not us­ing leg rests as di­rected by the res­i­dent’s care plan.

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

Fairview in Gro­ton was fined $2,030 af­ter com­plaints of abuse in­volv­ing one nurse aide were not doc­u­mented fully or in a timely man­ner.

Sev­eral com­plaints were lodged against the nurse aide be­tween May 25 and June 1, 2017, ac­cord­ing to DPH. Among them: The aide was “rough” when trans­fer­ring or treat­ing three res­i­dents; was seen “abruptly, al­most throw­ing” an­other res­i­dent; and re­port­edly told a res­i­dent, “While you are a res­i­dent here, I am the boss and you need to do what I say.”

The nurse aide was re­moved from the sched­ule on May 25, when the first in­ci­dent was re­ported. But most of the sub­se­quent in­ci­dent re­ports failed to in­clude dates when the in­ci­dents oc­curred. On

June 1, the fa­cil­ity started train­ing nurs­ing staff about manda­tory re­port­ing of abuse, ac­cord­ing to the ci­ta­tion.

“We self-re­ported these in­ci­dents to DPH and we took im­me­di­ate dis­ci­plinary and cor­rec­tive ac­tion,” said Fairview CEO James Rosen­man. “Our ded­i­cated and com­pas­sion­ate staff mem­bers have set the bar high for the level of care they pro­vide every day and we have no tol­er­ance for con­duct that falls be­low our high stan­dards.”

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