Four Connecticut nursing homes have been fined by the state Department of Public Health following injuries and falls, including one fall that later resulted in a resident’s death.
Avon Health Center was fined $1,090 because of two incidents. On March 14, a resident died six days after falling out of a mechanical lift and sling. The resident, who had several ailments including dementia, fell while being transferred from a wheelchair to a bed. The resident suffered brain hemorrhaging and a fracture at the base of the skull, and was treated at a local emergency room, according to the DPH citation. On March 20, the resident died.
An investigation found staff at the nursing home did not follow proper procedures when moving the resident from wheelchair to bed and used the wrong-sized sling when moving the resident. Staff said a sling clip detached from the lift, causing the resident to fall forward and land face down on the floor, according to the DPH citation.
Following the incident, training was provided to all staff operating lifts at the facility.
“While we disagree with some of the state’s findings, privacy laws prevent us from commenting on the care provided to specific residents,” said Avon Health Center Administrator Tina Richardson. “Avon Health Center is committed to providing quality care and services to all of our residents. As a result of this incident, we have performed an internal review of our processes and will continue to strive to improve the care we provide to all our residents.”
The other incident at the facility involved a resident falling. On March 25, a resident who had dementia, a broken right hip and other diagnoses – and who was flagged as being at a high risk for falling – was helped to the bathroom by a nursing assistant and was later found on the floor.
After being treated in an emergency room for a broken left wrist, the resident returned to the nursing home March 26. Investigators found the resident had been left unattended on the toilet when the fall happened. The nursing assistant did not know that the resident should not be left alone. A further review of medical records showed the same resident had a history of falls at the facility, the citation states.
Meriden Center was fined $1,020 after a resident fell from bed onto his or her face on Aug. 22. A nursing assistant admitted to picking up the resident, putting the person back in bed, making “sure (the resident) was breathing” and then leaving to give another resident a shower. The nursing assistant never reported the incident to a supervisor and later acknowledged being negligent in not doing so, according to DPH.
The resident, who had dementia, osteoporosis and anxiety, suffered bruising on a significant portion of the face, bruises on the left shoulder and part of the skull and cuts to the lips. The resident was treated at an emergency room and returned to the facility the next day. The nursing assistant involved in the incident was fired, according to DPH.
Officials at Meriden Center did not return a call seeking comment.
Touchpoint at Manchester was fined $1,090 for two separate incidents.
On Feb. 14, a resident who had multiple sclerosis, couldn’t walk and was at risk for falling was found on a shower room floor. The resident fell off a shower bench and hit the back of his or her head on a wheelchair. The resident was treated at a hospital and needed surgical staples for a scalp laceration, the DPH citation said.
An investigation found the resident usually showered in a room that had a shower chair, but on the day of the fall something was broken in that shower room. So the resident was moved to a shower that had a bench instead.The resident said the bench was not secure and had no back.
As a result of the incident, all shower benches have been removed from the nursing home, the citation noted.
Also in February, a resident suffered a right knee fracture after nursing home staff caught the resident’s knee in a lift they were using to move the resident from a wheelchair to a bed. The resident complained of knee pain and a hospital evaluation found fluid around the knee and a fracture.
The resident had diagnoses including dementia and osteoporosis and was completely dependent on two nursing home staff members helping him with transfers and bathroom use. An investigation found there was no intentional mistreatment or abuse but that the injury occurred during a transfer.
Officials at the facility did not return a call seeking comment.
Apple Rehab Laurel Woods in East Haven was fined $1,160 after inspectors found that records were not properly kept for a resident who suffered from dehydration in November 2013.
The resident suffered from kidney and urinary problems and was at known risk for dehydration.
DPH inspectors found that when staff gave the resident intravenous fluids to combat dehydration, they failed to document the resident’s assessment and didn’t note when the resident’s care plan was revised.
Documents did not reflect when nursing home staff intervened to hydrate the resident, even though medical records show the resident’s fluid intake being well below the recommended level from Nov. 12 to Nov. 25, 2013.
“Nurses were educated to the importance of documenting the patient’s assessment of dehydration, updating the care plan appropriately and notifying the MD as to the patient’s low fluid intake,” said Ann Collette, chief marketing officer at Apple Rehab Laurel Woods.
