State Fines Six Nursing Homes After Residents Injured

The state Department of Public Health (DPH) has fined six nursing homes for various violations that endangered or injured residents.

Masonicare Health Center in Wallingford was fined $3,900 after a resident developed a severe pressure ulcer.

On June 12, 2017, a resident who suffered incontinence and was a risk for skin breakdown was diagnosed with an unstageable deep tissue injury in the lower back. An advanced practice registered nurse determined the resident had the wrong type of mattress and recommended the use of a pressure-reducing cushion, according to DPH.

Once the resident received the cushion, it was under-inflated on multiple occasions and documentation from May through August failed to show staff were monitoring its inflation, according to the citation.

Margaret Steeves, vice president of marketing and communications at Masonicare, said patient safety is the facility’s top priority.

“Regarding this particular incident, Masonicare conducted an extensive review of practice and care delivered,” she said. “While we disagree with the findings, we will comply with the fine.”

Arden House in Hamden was fined $3,660 for four incidents in which residents were harmed.

On May 8, 2017, a resident suffered a hematoma on the left arm after a nurse aide pulled a call bell away from the resident, according to DPH. The resident hit the call button due to difficulty breathing. When the nurse aide tried to calm the resident, the resident began swinging the call bell, which led to the injury. The nurse aide was fired following an investigation, DPH said.

Another resident suffered a stage two pressure ulcer, which healed and then re-opened, according to DPH. The initial wound was diagnosed on Feb. 2, 2017, healed by Feb. 17, then later reappeared and worsened. Staff failed to notify other staff and the resident’s family when the wound worsened, according to the citation.

On May 22, 2017 a resident who required two-staff assistance for mobility fell to the floor after trying to stand up from a wheelchair without help, according to DPH. The resident was bleeding from the mouth and taken to an emergency department for evaluation.

On March 16, 2017, a resident was admitted to a local hospital with twitching, hypothermia, hypotension and septic shock due to multifocal pneumonia, according to DPH. An investigation found the resident’s fluid intake and output weren’t monitored from March 9 to March 16.

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

The Mary Wade Home in New Haven was fined $3,060 after a resident fell out of bed and suffered a femur fracture.

On June 1, 2017, one nurse aide was providing morning care to the resident, who required two-staff assistance for all care, and was rolling the resident over to the opposite side of the bed when the resident fell to the floor, according to DPH.

The resident was taken to a hospital and diagnosed with a right femur fracture. After being readmitted to the facility on June 2, it was discovered on June 9 that an immobilizer provided by the hospital was not on the resident properly, according to the citation.

“Following an incident which resulted in the injury of a resident last June, we took immediate disciplinary and corrective action to prevent any similar incident from occurring,” administrator Stanley DeCosta Jr. said. “Our entire staff was re-educated and trained on proper procedures for this type of resident care. The resident affected is fully recovered and continues to reside with us at Mary Wade Home.”

Chestelm Health & Rehabilitation Center in East Haddam was fined $3,060 after a resident was hurt in a fall.

On Sept. 15, 2017, a resident with severe cognitive impairment, who was required to have staff nearby when using the bathroom, fell while left unattended, according to DPH.

X-rays at the facility of the hips and pelvic area showed no fractures, but the resident was taken to a hospital three days later and x-rays there revealed several rib fractures and a hemothorax, or collection of blood in between the chest wall and the lung, according to the citation.

An investigation found the nurse aide left the resident alone to answer other residents’ call bells, according to DPH.

“There are times split decisions have to be made when caring for multiple residents,” administrator Brenda Marinan said. “Our staff are very dedicated, loving and compassionate people who were also upset over the resident injury. We support our staff and residents like family members. The resident has recovered and is happily residing with us.”

Rose Haven Ltd. in Litchfield was fined $3,000 after a resident suffered a skin tear on the back while being moved incorrectly by a nurse aide.

On April 9, 2017, one nurse aide tried to move the resident from a wheelchair to a recliner chair manually, despite a physician’s order that the resident required the help of two staff and a mechanical stand lift for all transfers, DPH said. The nurse aide didn’t know the resident required the help of two staff and was reassigned to another facility unit.

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

Douglas Manor in Windham was fined $1 after a resident, who was supposed to be checked for incontinence every two hours, was inadvertently left on a bedpan for five hours on Oct. 13, 2017.  The $1 fine is because the facility is in receivership, DPH said.

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

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