State Fines Nursing Homes Following Injuries To Residents

The state Department of Public Health (DPH) has fined four nursing homes for violations that resulted in injuries to residents.

Marlborough Health and Rehabilitation Center was fined $3,270 after a resident suffered two leg fractures when a nurse aide failed to transport the resident properly.

The resident, who had Alzheimer’s disease and other diagnoses, was screaming in pain with a swollen left leg on Nov. 27, 2017, and an X-ray at the facility showed a broken left femur. The resident was transferred to a hospital, according to DPH.

A follow-up exam at the hospital found a right femur fracture as well. An investigation found a nurse aide had tried to move the resident with a Hoyer lift without help even though the resident required two-person assistance. According to the citation, the nurse aide looked for someone to help but no one was available. The aide said the resident’s legs had swung against a dresser. The aide subsequently was fired.

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

Monsignor Bojnowski Manor in New Britain was fined $3,260 for two instances involving pressure ulcers.

A resident who had difficulty walking developed a pressure ulcer on the left heel Feb. 11, and a physician’s order subsequently directed staff to start various treatments, including off-loading the resident’s heels with boots at all times. According to the citation, the resident developed a pressure ulcer on the right heel by Feb. 21, and records didn’t indicate that the heels had been off-loaded as directed.

Another resident was identified in January 2018 as being at risk of developing pressure ulcers and was supposed to receive various precautions to prevent them, according to DPH. The resident developed a pressure ulcer on Feb. 16. According to the citation, one treatment—skin prep applied to the heels— had been initiated in January but documents failed to show whether it had resumed after the resident returned to the facility on Jan. 28 following a brief hospitalization.

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

Waterbury Gardens for Nursing and Rehabilitation was fined $1,530 after a diabetic resident was hospitalized due to an insulin overdose.

The resident was taken to a hospital on Aug. 25, 2017, after being found on a dining room floor next to a wheelchair and bleeding from a forehead laceration. Hospital staff determined the resident had been given too much insulin medication Aug. 22 through Aug. 25, causing the resident to develop hypoglycemia, the DPH citation said. An error had been made in an electronic medication administration record, the citation said.

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

Apple Rehab Rocky Hill was fined $1,410 after a resident died with an elevated potassium level.

The resident was found in a room on Feb. 27 with no pulse, no blood pressure and not breathing, according to DPH, and was pronounced dead several minutes later. The resident had atrial fibrillation and other cardiac conditions and had been medicated to treat high levels of potassium.

An investigation found a registered nurse earlier had mistakenly reported the resident’s potassium level to an advanced practice registered nurse as being 6.0 millimoles per liter, when it actually was a critically high 7.0 millimoles per liter. Had the RN reported the level accurately, the resident likely would have been given an echocardiogram and transferred to an emergency department, according to the citation.

A physician told investigators the error likely didn’t contribute to the resident’s death, according to DPH.

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

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