Four Connecticut Nursing Homes Fined For Lapses In Care

June 22, 2016
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Four nursing homes have been fined by the state in connection with residents who broke bones, required surgery or wandered away.

In two separate citations on April 8, Cassena Care at Norwalk was fined a total of $5,370 for a case in which a now former director of nursing blocked a resident from going to the hospital to maintain the resident count at the home, state records show.

A day after the incident, on Oct. 10, the resident needed emergency cranial surgery and then was placed in hospice care, a citation from the state Department of Public Health said. DPH officials did not have information on whether the resident had died, department spokeswoman Maura Downes said.

The home was fined $3,000 in one DPH citation that said the resident had a change in mental status, was lethargic and difficult to arouse, but an ambulance call was cancelled. A registered nurse said that the former nursing director had ordered the staff to try to keep residents at the home to maintain the resident census, the citation said.

A doctor had ordered the resident sent to the hospital and received a text that the director had refused to do so, the citation said. The doctor did not follow up, thinking the resident had been hospitalized, the citation said.

The home was fined $2,370 in connection with the same resident’s care, a second citation said. A doctor said he should have been notified that the resident had not gone to the hospital as ordered on Oct. 9 and he should have been told of the change in the resident’s mental status, the citation said.

Officials from the home could not be reached for comment.

On May 23, Meadowbrook of Granby was fined $1,815 in connection with a resident who rolled out of bed on Jan. 23 and broke a hip.

After the fall, the resident was hospitalized but returned to the home with no documentation showing that the hips had been X-rayed, the citation said. Two days later, the person was in pain and was sent back to the hospital, where X-rays showed a broken hip, the citation said. The resident underwent surgery to repair the hip.

The state found that a nurse’s aide had raised the bed to care for the resident, but went to a bathroom and should have lowered the bed before leaving the resident’s side, the citation said. The aide was re-trained about the importance of lowering the bed, the citation said. Administrator Rachel DeMaida declined to comment.

On Aug. 24, Bridgeport Health Care Center was fined $640 in connection with a resident who left the facility Aug. 1 and was found at a store down the road.

A video showed the resident climbed over a patio wall. The person made it seven tenths of a mile before being returned safely to the home about an hour later, the citation said.

The home failed to follow its policy of having a photo of every resident who needed one-on-one monitoring at the front desk, the citation said. The director of nursing told state inspectors that a licensed practical nurse should have asked one person to watch the resident, the home should have called a special code and the supervisors should have met to plan a search for the resident, the citation said.

In response to the incident, a plan was put in place involving residents who were at risk for wandering, and all of the staff members were re-trained, the citation said.

On April 20, Greenwich Woods Rehabilitation in Greenwich was fined $630 in connection with a resident who fell on March 6 and broke a thigh bone.

The resident was found on the floor and initially did not appear to be injured. Two days later, a registered nurse changed the electronic medical record to say that on March 6, the resident was in pain and the injured leg appeared to have shortened by one inch, the DPH citation said.

The nurse did not notify a doctor, did not obtain an order for an X-ray and changed the record at the direction of a director of nursing services who is no longer at the home, the citation said. After an advanced practice registered nurse ordered X-rays on March 7, the fracture was diagnosed and the resident was hospitalized, the citation said.

Administrators at Bridgeport Health and Greenwich Woods could not be reached for comment.health logo

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