Blair Manor in Enfield was fined $3,000 after a resident with dementia and neurocognitive disorder left the facility.
Staff noticed the resident was missing around 7:20 p.m. on Oct. 4, 2016. According to the Department of Public Health (DPH) citation, earlier that day five staff members separately witnessed the resident saying he was going to leave the facility and packing his belongings, but none reported it to their supervisors.
DPH found that a registered nurse waited 45 minutes to call 911 after staff realized the resident was gone. Police found the resident at 10:50 p.m., after a Silver Alert was launched. The resident was taken to the hospital and returned to the facility Oct. 5 and was placed on 1-to-1 observation, according to DPH, but ultimately became agitated and was taken to the hospital Oct. 7 and didn’t return to the facility.
An investigation found the resident had previously threatened to leave the facility several times in August. Officials at the facility did not return a call seeking comment.
RegalCare at New Haven was fined $750 after a resident with bipolar disorder removed a monitoring device and left the facility.
Staff noticed the resident was missing at 7 a.m. on Sept. 7, 2016. The resident was found more than four hours later at someone’s home, about 7 miles away, according to DPH.
An investigation found the resident had not been checked since 11 p.m. the previous night, even though staff should have been performing checks every 15 minutes. Also, an elevator lock that prevents access to the facility’s basement was not working, which allowed the resident to leave via the basement, according to the citation.
A nurse, who knew about the broken elevator lock but didn’t report it, was fired, according to DPH.
Officials at the facility did not return a call seeking comment.
Miller Memorial Community Inc. in Meriden was fined $2,310 after a resident fell while receiving incontinence care.
On Oct. 6, 2016, a resident suffered an orbital fracture and a head laceration that required sutures and staples after falling onto the floor while a nurse aide provided incontinence care. The resident’s care plan called for two-person assistance for incontinence care, but the nurse aide tried to stand the resident up without help because the resident was agitated and impatient, according to the citation.
The nurse aide was fired for not following the resident’s care plan, according to DPH.
Officials at the facility did not return a call seeking comment.
Jerome Home in New Britain was fined $1,600 after a resident with vascular dementia and anxiety disorder was hurt in a fall on Oct. 6, 2015.
The resident suffered a laceration to the forehead that required sutures after falling onto the floor from a wheelchair while being transported by a nurse aide. According to the citation, the aide was carrying linens in one hand and pushing the wheelchair with one hand, and the resident’s wheelchair did not have a footrest.
“Patient safety is a huge priority here for us,” said Jerome Home Executive Director Lori Toombs. “We did implement additional training for staff and audits, to make sure proper protocols are followed.”
Trinity Hill Care Center of Hartford was fined a total of $750 for two separate incidents.
In one, staff told a resident with stage 4 lung cancer that all visits from family had to be supervised by staff and limited to 30 minutes. According to the citation, staff decided to restrict the resident’s visitation due to a history of substance abuse, but an investigation found the resident should have been allowed unsupervised family visits.
In a separate incident, staff delayed following a hospice nurse’s recommendation to adjust a resident’s medication dosage. The resident, who had hepatic encephalopathy, received morphine sulfate for pain but a hospice nurse determined on Jan. 28, 2016, that the dose wasn’t enough to provide relief, according to the citation. It wasn’t until Jan. 31 that a physician’s order was updated to include the increased dosage ordered by the hospice nurse, DPH found.
“Trinity Hill Care Center is committed to upholding the highest standards of care for its residents,” said George Kingston, administrator at Trinity Hill. “The center developed an approved plan of correction, which included revision to operating policies and in-servicing staff. Trinity Hill Care Center remains in full compliance with all federal and state regulatory requirements.”
