Three Connecticut Nursing Homes Fined Following Resident’s Death, Care Lapses

State health officials have fined three Connecticut nursing homes for various incidents, including one in which a resident died last year.

Apple Rehab Farmington Valley in Plainville was fined $2,140 for three violations that occurred in 2016. In one case, a resident died Oct. 23 after choking during dinner.

The resident, who had dementia, was found by a licensed practical nurse (LPN) choking in bed. The LPN delivered dinner to the resident, who was on a “mechanical soft diet” due to difficulty chewing, and had left the room after cutting the food for the resident, according to a state Department of Public Health (DPH) citation.

The LPN told investigators that a piece of garlic bread with the meal seemed hard and was difficult to cut, but the LPN left it on the plate since it was permitted on the resident’s diet. According to DPH, when the LPN returned to the room the resident was choking.

Staff performed the Heimlich maneuver, finger sweeps and abdominal thrusts. When paramedics arrived, a cardiac monitor showed no electrical activity or blood flow to the heart, according to DPH. The resident had do-not-resuscitate directives in place and was pronounced dead.

In another incident, a resident with a shellfish allergy was served shrimp gumbo on Nov. 7. The resident complained of difficulty swallowing and was given allergy medications Benadryl and Solu-Medrol, which helped.

According to DPH, policy dictates all staff should check for allergies and diet restrictions before serving residents food. Staff was educated about the policy, the citation said.

In another case, a resident with gastric cancer who complained of increasing pain likely missed six doses of a narcotic painkiller that a physician had prescribed, according to the citation.

The resident was supposed to receive the medication every four hours, but it is unclear how much medication the resident received between Oct. 28 and Oct. 30. According to DPH, documentation was incomplete. Officials at the facility did not return a call seeking comment.

Madison House in Madison was fined $2,310 after a resident suffered right arm bruising and swelling and DPH determined staff didn’t provide bed mobility and perform transfers properly.

The resident was taken to an emergency department on Feb. 20 and admitted to the hospital, according to DPH. The resident did not return to the facility at the family’s request.

The citation said two nurse’s aides, on separate occasions, moved the resident without the help of a second person, even though the resident’s care plan called for two-person assistance. Staff was re-educated on how to transfer residents safely, according to DPH.

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

Parkway Pavilion Health & Rehabilitation Center in Enfield was fined $1,530 for a Jan. 2 incident in which a nurse’s aide touched a resident’s vaginal area while repositioning the resident in bed.

According to the citation, the resident—who had her right leg amputated above the knee, a fractured right elbow, and other diagnoses—had a care plan stipulating that two staff members were to assist with bed positioning, but a nurse aide believed a second staff member was unnecessary.

The facility fired the aide Jan. 6.

“This isolated incident was immediately reported to the local authorities and all appropriate regulatory agencies,” said Sharon Ellis, the facility spokeswoman. “The facility investigated the matter and took all necessary actions to ensure our ongoing compliance with state and federal regulations. We place the health and safety of our residents as our top priority.”

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