On Feb. 6, a resident with dementia and depression entered another resident’s room with a knife and made a threatening gesture to cut the resident’s neck with a butter knife and drink the blood, according to the DPH citation. A nurse aide in the room tried to take the knife but the resident put the knife under a cushion. A nurse was called and retrieved the knife. Following the incident, police, family members and administrators were notified and the resident who was threatened received emotional support.
About an hour after the incident, the resident who made the threat was placed on one-to-one supervision, which was to remain in effect until the resident was transported to a hospital. But a shift nurse later that day removed the one-on-one supervision “due to inadequate staffing” and no other safety precautions were put in place, according to the citation.
The citation said that prior to the threatening incident the resident with dementia and depression was found “obtaining and holding knives and hitting the walls with a knife and grabbing knives off the silverware cart” on Jan. 13, Jan. 21, Jan. 29 and Jan. 31. No interventions were implemented to the resident’s care plan, DPH said.
On Feb. 1, when the resident was found hoarding knives, an intervention was implemented, the citation states.
Officials at the facility didn’t return a call seeking comment.
Apple Rehab Middletown was fined $3,880 for three incidents.
On March 23, a resident with Huntington’s disease was transported to a hospital after experiencing shortness of breath, a weak pulse and a low-grade temperature. At the hospital, the resident was diagnosed with acute respiratory failure and likely sepsis, according to DPH.
An investigation found that between Sept. 14, 2017, and March 23, 2018, the resident was not weighed weekly and the resident’s output was not monitored. Documentation also showed the resident frequently refused meals but was not assessed for dehydration, according to the citation.
In another instance, a resident with a left leg fracture did not receive prescribed doses of an anti-coagulant medication March 3-5. According to DPH, a stop date was placed on the medication after March 2, but documentation showed no physician’s order directing the stoppage.
Also, a resident with heart disease failed to receive nine medications on Jan. 25, and the resident’s physician was not made aware of it.
Officials at the facility did not return a call seeking comment.
Orchard Grove Specialty Care Center in Uncasville was fined $3,270 after a resident was hospitalized with low blood pressure.
The resident was taken to a hospital on June 3 after staff noticed that the resident was lethargic and experienced shortness of breath, according to DPH. The resident arrived at the hospital with wheezing, rapid heart rate and decreased responsiveness, and was intubated and put on antibiotics due to sepsis.
An investigation found a physician’s order for the resident’s blood pressure to be taken weekly, but the clinical record failed to show any blood pressure readings after May 20. Also, a medication log didn’t show medication was administered to alleviate the resident’s shortness of breath.
Officials at the facility, run by Apple Rehab, didn’t respond to a request for comment.
Riverside Heath and Rehabilitation Center in East Hartford was fined $860 after a resident drank perineal cleanser.
The resident, who has dementia, was found May 17 taking a sip from a cup that contained purple liquid and ice. Staff called Poison Control but documentation failed to show first aid measures were implemented or that the resident was properly monitored for possible reactions. Also, a registered nurse failed to document the incident in the resident’s clinical record.
Officials at the facility didn’t return a call seeking comment.
Maefair Health Care Center in Trumbull was fined $660 after a resident who was a known risk for elopement was found wandering in the facility’s parking lot with several injuries.
On June 14, staff found the resident in the parking lot with a skin tear on the left knee, a scratch on the left pinky and a lump on the right upper arm, according to DPH. The resident had been last seen at the nursing unit at 6:30 p.m. and was found outside 15 minutes later.
Two nurse aides subsequently told investigators that in the days leading up to the incident they had seen the resident try to leave the unit. Door alarms that should have sounded, they said, didn’t sound in one instance and were difficult to hear in another, according to the citation.
Following the incident, the facility “immediately ensured for the well-being of its resident and tested its internal mechanisms to prevent accidental elopement by its patients and residents,” said Tim Brown, marketing and communications director for parent company Athena Health Care Systems. “Staff interviews and re-education on center policies and procedures to prevent elopement by at-risk patients were also conducted.”
