By Cara Rosner
The state Department of Public Health (DPH) has fined four nursing homes for violations that resulted in resident harm.
Village Crest Center for Health and Rehabilitation in New Milford was fined $10,000 for two violations.
On June 14, 2019, two residents were found by a dietary aide walking outside near the facility. One of the two residents had fallen and was an elopement risk, but wasn’t identified as one in documentation, DPH said. As the residents were leaving the facility, a receptionist who saw them thought that one of the people in the foyer was a guest, signing the resident out, according to the DPH. Following the incident, staff were educated about how to manage elopement risks.
On June 28, 2019, six residents – with diagnoses including dementia, Parkinson’s disease, a psychotic disorder and anxiety – were seen without identification bracelets, including the two residents who left the facility on June 14. A nurse’s aide said one of the residents had removed his or her bracelet and it was on a dresser, and another resident’s bracelet was on a walker, according to DPH.
Watertown Convalarium was fined $9,260 for two violations.
A resident who required the help of a Hoyer lift and two staff to move out of bed, and who was at risk for developing pressure ulcers, was observed not leaving the bed at all between Nov. 26 and Nov. 29, 2018, according to DPH. On Nov. 29, the resident was found to have significant contractures, or shortening and tightening of muscles, in both legs. Staff said the resident’s contractures made it difficult for the resident to sit in a wheelchair so the resident was not moved out of bed.
On Nov. 26, 2018, an inspector saw a licensed practical nurse perform a blood glucose test on a diabetic resident and then clean the glucometer with an isopropyl alcohol wipe, instead of the Super Sani-Cloth germicidal disposable wipe that should have been used, according to DPH. The LPN had previously been trained in how to properly clean glucometers, and staff was retrained following this incident.
Middlebury Convalescent Home was fined $6,120 after a resident fell several times, including one time that caused a head injury.
The resident, who was identified as being a fall risk, was found sitting on the floor beside the bed on April 26, 2019. The resident wasn’t injured in that fall but staff were directed to add non-skid strips to the floor beside the bed to prevent similar incidents, according to DPH. The resident fell two more times, including on May 4, when the resident was found on the same area of the floor and suffered a head laceration that required 10 staples at a hospital.
According to the citation, staff didn’t apply the non-skid strips to the floor until May 8. A maintenance supervisor said the strips weren’t applied sooner because there were not enough materials available to complete the job.
“For 58 years, our facility has considered resident safety our utmost priority. We have appealed the state’s finding in this situation and maintain our stance of disagreement with their judgment,” the facility said in a statement. “We have had many stellar surveys in the past and expect this situation to be an anomaly not to be repeated.”
Grove Manor Nursing Home in Waterbury was fined $3,060 after a resident was hurt while being moved by staff.
On April 24, 2019, two nurse aides were transferring a resident from a bed to a wheelchair with a Hoyer lift when the resident’s right leg got caught behind a leg rest on the wheelchair. According to the citation, wheelchair leg rests should have been removed prior to the transfer, but the nurse aides didn’t remove them because the resident was agitated and they tried to transfer the resident quickly.
The resident was taken to a hospital and diagnosed with a right leg fracture. Investigators found the facility’s Hoyer lift transfer policy didn’t say wheelchair leg rests should be removed prior to transfers, which it should have, according to DPH. Following the incident, all staff were re-educated on how to properly transfer residents with a Hoyer lift.
Officials at Village Crest, Watertown Convalarium and Grove Manor did not return a call seeking comment.
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