More nurs­ing homes fined

DPH cites care lapses at fa­cil­i­ties

The Register Citizen (Torrington, CT) - - FRONT PAGE - By Cara Ros­ner Conn. Health I-Team Writer

The state Depart­ment of Pub­lic Health has cited and fined four Con­necti­cut nurs­ing homes for var­i­ous lapses of care.

Ma­soni­care Health Cen­ter in Walling­ford was fined $1,635 for a Feb. 2, 2016, in­ci­dent in which a res­i­dent’s catheter tube be­came dis­lodged while staff trans­ported the res­i­dent to the bath­room. Af­ter the catheter be­came dis­lodged, a new one was in­serted at a hos­pi­tal but pieces of the old one re­mained in the res­i­dent, who suf­fered from blad­der in­flam­ma­tion. The res­i­dent was sched­uled for surgery to re­move the re­main­ing pieces, the ci­ta­tion said.

Mar­garet Steeves, Ma­soni­care spokesper­son, said the res­i­dent’s med­i­cal needs were met ef­fi­ciently, but the in­ci­dent was not re­ported to nurs­ing man­agers in a timely man­ner. Staff was re­minded about the im­por­tance of re­port­ing in­ci­dents right away, she said.

“The health and safety of our pa­tients is our top pri­or­ity,” she said.

Bridge­port Manor was fined $1,940 for two in­stances ear­lier this year. In a Jan. 14 in­ci­dent, a nurse aide found a res­i­dent slumped in a wheel­chair with the wheel­chair safety belt around the neck. Ac­cord­ing to the ci­ta­tion, the res­i­dent’s head and neck were on the seat of the wheel­chair, the wheel­chair’s seat­belt was chok­ing the res­i­dent and the res­i­dent’s lips were turn­ing blue.

The res­i­dent was ex­am­ined at a hos­pi­tal and re­turned to the fa­cil­ity the same day, DPH said.

An in­ves­ti­ga­tion found that sev­eral staff had pre­vi­ously re­ported the wheel­chair’s seat­belt was loose, but main­te­nance work­ers said it was fine. Staff sub­se­quently no­ticed the seat­belt wasn’t work­ing prop­erly but failed to re­port it, ac­cord­ing to the ci­ta­tion.

In a sep­a­rate case, on Jan. 19, a res­i­dent on a diet of pureed food choked on a piece of pizza, turned blue and be­came un­re­spon­sive. Staff per­formed ab­dom­i­nal thrusts and ad­min­is­tered oxy­gen be­fore the res­i­dent was trans­ported to a hos­pi­tal.

An in­ves­ti­ga­tion found the res­i­dent, who had Parkin­son’s dis­ease and gas­troe­sophageal re­flux, took a piece of pizza from an­other res­i­dent’s plate dur­ing a re­cre­ation pro­gram, DPH said.

Of­fi­cials at the fa­cil­ity did not re­turn a call seek­ing com­ment.

Beech­wood in New Lon­don was fined $1,840 for two in­ci­dents that oc­curred in De­cem­ber 2016. In one case, a res­i­dent with dementia left the fa­cil­ity in a wheel­chair around 5 a.m. on Dec. 9. Staff found the res­i­dent about 10 min­utes later at a home across the street, the ci­ta­tion said.

The res­i­dent had been ag­i­tated the pre­vi­ous night, was wit­nessed pack­ing clothes and tried to leave, DPH said. An in­ves­ti­ga­tion de­ter­mined that nurse aides should have re­ported to the charge nurse that they saw the res­i­dent pack­ing clothes. All staff re­ceived train­ing on res­i­dents who are elope­ment risks (at risk for leav­ing the fa­cil­ity).

In a sep­a­rate in­ci­dent on Dec. 6, a res­i­dent was mis­tak­enly given a med­i­ca­tion that caused an al­ler­gic re­ac­tion. The res­i­dent, who had end-stage re­nal dis­ease and other di­ag­noses, was given Coumadin, a blood thin­ner, de­spite doc­u­men­ta­tion not­ing an al­lergy to the med­i­ca­tion, ac­cord­ing to DPH. The res­i­dent be­came lethar­gic and was slur­ring words. The res­i­dent was taken to a hos­pi­tal and dis­charged back to the fa­cil­ity the fol­low­ing day. Investigators found a Beech­wood staff nurse ac­ci­den­tally gave an­other res­i­dent’s med­i­ca­tion to the res­i­dent.

Beech­wood Ex­ec­u­tive Di­rec­tor Katie Lasewicz de­clined to com­ment.

Re­gal­care at Prospect was fined $1,000 af­ter a nurse aide cashed checks be­long­ing to a res­i­dent to­tal­ing $2,245 with­out the res­i­dent’s knowl­edge. The res­i­dent, who suf­fered from al­co­hol abuse and epilepsy, was at the fa­cil­ity from May 22, 2015, to Nov. 16, 2016, and was in­structed to keep valu­ables in a locked drawer, though the res­i­dent told staff it wasn’t im­por­tant to do so, the ci­ta­tion said.

Be­tween Feb. 8 and Nov. 24, 2016, the nurse aide cashed 16 checks. The res­i­dent pressed charges against the aide who was sus­pended from the fa­cil­ity in Novem­ber 2016, ac­cord­ing to DPH. Af­ter fail­ing to keep an ap­point­ment at the fa­cil­ity to pro­vide a state­ment, the aide was fired Dec. 2, 2016. Of­fi­cials at the fa­cil­ity did not re­turn a call seek­ing com­ment.

This story was re­ported un­der a part­ner­ship with the Con­necti­cut Health I-Team (www.c-hit.org).

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