By Cara Rosner

Four Connecticut nursing homes have been fined by the state Department of Public Health (DPH) after inspections uncovered various violations, most of which caused injuries to residents.

River Glen Health Care Center in Southbury was fined $10,000 for two instances in which staff failed to use wheelchair foot rests, injuring residents.

On July 22, 2018, a resident with dementia fell from a wheelchair while being moved by a licensed practical nurse. With feet down on the floor, the resident propelled forward from the chair, fell and suffered an injury to the forehead, according to DPH.

An investigation found foot rests should have been on the wheelchair but were not. According to the citation, the facility had no policy for leg or foot rest use, but the expectation was that they should have been used in this case. The resident was taken to a hospital and received three sutures for a forehead laceration.

On March 12, a nurse aide was pushing a resident in a wheelchair toward a shower room when, according to the nurse aide, the resident complained about the wheelchair cushion, leaned forward and fell face-first onto the floor. The resident was treated at a hospital for a forehead laceration and nasal bone fractures. The nurse aide said there were no foot rests on the wheelchair, according to the citation.

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

Avery Heights, also known as Avery Nursing, in Hartford was fined $6,120 after a resident with dementia was injured in a fall.

The resident, who was identified as being at high risk for falls, fell onto a bathroom floor on Oct. 13, 2018. A nurse aide had helped the resident to the bathroom and told the resident to wait on the toilet while the aide got more towels, according to DPH.

When the nurse aide returned, the resident was getting up from the toilet and fell. According to the citation, the resident was taken to a hospital and treated for a broken right arm and a head laceration that required three staples.

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

The Watermark at East Hill in Southbury was fined $6,120 after a resident suffered a broken femur in a fall.

A nurse aide was providing incontinence care to the resident, who had dementia and was a known fall risk, on March 15. The resident’s care plan called for two-staff assistance for bed mobility, but the nurse aide was providing care without help, according to DPH.

After removing floor mats on the side of the bed, and moving the bed to a higher position, the nurse aide turned away from the resident to get an incontinence pad from a cabinet, and the resident fell onto the floor, according to the citation.

The resident complained of left hip pain and was treated at a hospital for a broken left femur. According to DPH, the nurse aide should have had the resident’s bed on the lowest setting when providing care and should have gathered all needed supplies ahead of time.

“The safety and well-being of our residents is our top priority,” said Executive Director Jeffrey Williams. “At the time of the occurrence, we immediately self-reported the incident and performed an extensive internal investigation, which determined that the individual involved did not follow our training and protocol. That individual was terminated from his position as a CNA [certified nursing assistant ] and we utilized this opportunity to retrain our entire care team.”

For the next two months, a member of the nursing team observed delivery of care services to ensure the facilities protocol was understood and consistently followed, Williams said.

Greentree Manor Nursing & Rehabilitation Center in Waterford was fined $3,820 after a resident inappropriately touched two other residents and a 4-year-old visitor.

The resident—who had shown a pattern of sexual, inappropriate behaviors—was to be checked on by staff every 15 minutes and have one-on-one room supervision.

On Feb. 6, 2018, the same resident was accused of grabbing another resident’s breast, but no staff witnessed the incident. The accused resident was put on one-on-one supervision until the next day, when psychiatry staff recommended the supervision be downgraded to checks every 15 minutes, the citation said.

On Feb. 17, 2018, another resident reported seeing the same resident grab another resident’s groin on a couch outside the director of nursing’s office. Also that day a licensed practical nurse saw the resident near a nurse’s station reach an arm around a 4-year-old visitor and grab the child’s buttocks, according to DPH.

In all three cases, staff should have been monitoring the resident and redirecting the resident away from the other residents and the visitor, according to the citation.

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

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