On March 15, Leeway Inc. of New Haven was fined $3,000 in connection with a resident who was hospitalized on Feb. 23 with low levels of phosphate and potassium after a medication error. The resident was not given seven doses of potassium chloride despite a doctor’s order, the state Department of Health citation said. A registered nurse said later that she was tired and missed the order, the citation said.
There was a second medication error once the resident returned to the home, and the same nurse missed the doctor’s order for three doses of an anti-depression drug, the DPH citation said. The nurse could not explain why the error happened.
Administrator Heather Aaron said additional auditing of medications is now taking place.
“There was not a pattern here of medical errors,’’ she said. “This was an individual circumstance that we self-reported to the state.”
On May 4, Salmon Brook Center in Glastonbury, which is owned by Genesis Health Care, was fined $1,840 in connection with a resident who fell out of a wheelchair on Dec. 1 and broke a hip after a nurse’s aide left the person at a nurse’s station. Another nurse’s aide did not recall being asked to watch the resident and had gone to assist another resident when the first one fell, the citation said.
The director of nursing said the staff should have been supervising the resident at all times, the citation said.
The home was also cited in connection with a resident with dementia who was able to leave the home on July 4. A video showed a dietary aide had let the resident through a door into a service hallway, where the resident was left alone and got out to a parking lot, the citation said. The home then re-trained the staff on not allowing residents to go into a service hallway unless accompanied by a staff member.
Another Genesis home, The Willows in Woodbridge, was fined $1,635 on April 28 in connection with a resident who fell from a wheelchair on July 14, 2015 and sustained a broken leg.
A nurse’s aide reported turning away from the resident when the resident stood up and fell, the citation said.
In two April 22 citations, The Reservoir in West Hartford, another Genesis home, was fined a total of $1,275 in connection with incidents in May 2015 and September 2015.
The home was fined $735 in connection with a resident who became agitated and refused to go to an emergency room on May 9, 2015. The resident then called 911 and claimed to be in danger, the citation said. The police arrived and sent the resident an emergency room to be evaluated.
DPH found that an advanced practice registered nurse or doctor should have been informed when the resident initially refused to go to the emergency room.
The Reservoir was fined $540 in connection with a newly admitted resident who missed 22 doses of an anti-coagulant medication in September 2015 after a registered nurse supervisor neglected to confirm the medication order, the citation said.
In response to the incident, the staff developed a new protocol verifying medication orders for new admissions, the citation said.
Jeanne Moore, a Genesis spokeswoman, released the following statement in response to the citations: “When a Genesis center receives a deficiency and fine, the center works closely with the state survey agency to quickly regain compliance. The center also provides additional staff education and training when appropriate. Genesis HealthCare centers are committed to providing quality care to its patients and residents.”
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