Nursing Homes Fined Following Resident’s Death, Escapes, Falls

Posted By: Ct Health I Team September 25, 2019

By Cara Rosner

The state Department of Public Health has fined four nursing homes, including an Enfield facility where a resident died.

Parkway Pavilion Health and Rehabilitation Center in Enfield was fined $10,000 for multiple violations. On March 20, a resident was found unresponsive, sitting upright with vomit on the face. The resident was pronounced dead by emergency services personnel 15 minutes later.

Records show that CPR wasn’t initiated until five minutes after staff found the resident, and 911 was called one minute after that. According to the citation, a licensed practical nurse did not use an automated external defibrillator device because “she did not think to do so,” and she couldn’t explain why she didn’t call a “code blue,” to begin CPR or call 911 immediately after finding the resident.

Separately, a resident with congestive heart failure should have received a dose of iron sulfate every Monday, Wednesday and Friday, according to a Feb. 15 physician’s order. According to DPH, the resident erroneously received the medication daily from Feb. 16-21.

On March 1, a resident suffered a head laceration in a fall after a nurse aide left the resident alone to go into another room to get a wheelchair, according to DPH. The resident received four staples at a hospital. In another incident on March 10, medications were given to six residents at 5 p.m. instead of 9 p.m. as ordered, according to the citation.

Sharon Ellis of Wachusett Healthcare, the parent company of Parkway Pavilion, responded to the March 20 incident. In an e-mail, Ellis said, “This isolated incident took place in March, 2019 and was immediately reported to the local authorities and all appropriate regulatory agencies.  The facility investigated the matter, terminated the employee immediately and took all necessary actions to ensure our ongoing compliance with state and federal regulations.  The facility remains in full compliance with all state and federal regulations.  We place the health and safety of our residents as our top priority at all times.”

Trinity Hill Care Center in Hartford was fined $6,300 for several violations, including three instances when residents left the facility.

On June 8, 2018, a resident with schizophrenia left the facility without staff’s knowledge. Surveillance video showed the resident leaving the facility behind emergency medical service workers, according to the citation. The resident took a city bus to a nearby town to visit a family member, who returned the resident to the facility.

Police called the facility on June 24, 2018, at 9:46 p.m. with a resident in custody. The resident refused to return to the facility and was sent to an emergency department for evaluation, according to DPH. Surveillance video showed the resident walking outside the facility at 8:05 p.m., and an investigation found the resident likely exited through a secured stairwell door when a staff member exited.

On July 2, 2018, a resident called 911 because of chest pains and was taken to an emergency department, according to DPH. That resident later was seen walking down the street near the facility. After admitting to going to a bar and drinking alcohol, the resident was taken to another hospital for evaluation and tested positive for cocaine. Once the resident returned to the facility, staff failed to perform every-15-minute checks as directed. Then, on July 6, the resident managed to leave the facility again, this time leaving through a door that should have been secured but was propped open by a staff member who was repairing it.

On July 12, 2018, the facility ran out of the painkiller Tramadol, as well as its emergency supply, and had none to give a resident who was in pain. The facility policy was to order a medication 72 hours before its supply was depleted, according to DPH, but no refills for Tramadol had been ordered since June 22.

Orchard Grove Specialty Care Center in Uncasville was fined $7,800 after a resident fell three times.

The resident, who was a fall risk and whose care plan called for two-staff assistance for all transfers, fell onto the floor on Dec. 27, 2018, after being transferred by only one staff member, the citation said. On April 12, 2019, the resident was again being moved by only one staff member when the resident became unbalanced and fell onto the floor.

On July 2, 2019, the same resident became weak while being moved by a nurse aide from a bed to a wheelchair and was “assisted to the floor,” according to the citation. The resident was diagnosed with a left shoulder fracture at an emergency department. An investigation found the nurse aide tried to transfer the resident alone, had not looked at the resident’s care card, and was unaware the resident required two-staff assistance.

Three Rivers in Norwich was fined $6,120 after a resident was hurt in a fall.

On Jan, 21, the resident fell during a Hoyer lift transfer, sustaining a five-centimeter skin tear on the left hand and subsequently being diagnosed at a hospital with a broken right femur.

An investigation found two nurse aides trying to move the resident from a bed to a wheelchair were arguing about their workload “to the point of causing an unsafe Hoyer transfer,” according to the citation. At one point, one of the aides got angry and left the room, and the remaining aide tried to move the resident without help. Both nurse aides were fired.  Also, according to documents, the lift was missing safety clips.

Officials at Trinity Hill, Orchard Grove and Three Rivers did not return phone calls seeking comment.

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