Gardner Heights Health Care Center in Shelton was fined $3,480 after a resident who was known to have difficulty swallowing choked on a lasagna noodle.
The resident choked in a dining room on April 24. Staff performed the Heimlich maneuver several times with no success, according to DPH. When the resident subsequently was suctioned, a three-inch-long lasagna noodle was removed; the resident soon became more responsive, had improved color and began talking again.
According to the citation, the resident’s care plan outlined various feeding precautions, including constant supervision while eating and small bites of food. A nurse aide said the resident began choking while the aide was helping another resident, and the resident typically didn’t begin eating before the food was cut into small pieces.
Officials at the facility didn’t return a call seeking comment.
Portland Care & Rehabilitation Centre Inc. was fined $3,260 for two separate violations.
On April 21, a resident suffered an accidental overdose of morphine after charge nurse administered 2.5 cubic centimeters of the pain medication, instead of the 0.25 cubic centimeters ordered by a physician, the citation reports.
The nurse immediately noticed the mistake and notified a physician and the resident’s responsible party. The resident was treated at a hospital for an unintentional overdose and returned to the facility April 22, according to the citation. The nurse later said she had been rushing when she administered the morphine and then realized the syringe was larger than usual.
On May 23, a resident who was an elopement risk left the facility after a nurse aide mistakenly let the resident leave.
Staff noticed the resident, who had dementia and had tried to leave the facility eight times between May 17 and May 22, was not in bed at 1:30 a.m. and began a search. According to DPH, the resident wore a WanderGuard sensor but no alarm sounded when the resident left. Staff called 911 and police found the resident “roaming the streets,” according to the citation.
The resident was taken to a hospital but was uninjured. An investigation found a nurse aide had mistakenly thought the resident was a visitor, according to the citation. The door alarm sounded when the resident approached, but the aide didn’t think it was because of a WanderGuard. The aide deactivated the alarm and allowed the resident to exit.
The aide no longer works at the facility, according to DPH.
Officials at the facility didn’t return a call seeking comment.
Crestfield Rehabilitation Center and Fenwood Manor in Manchester was fined $3,060 after a resident suffered second-degree burns from a heat pad staff applied.
On May 7 the resident suffered a burn measuring six-by-five centimeters, according to DPH. The resident had complained of lower back pain and, according to nursing staff, the resident’s family requested heat pads be applied on May 5, May 6 and May 7.
According to the citation, the resident complained that the pad applied on May 7 was too hot, but the resident couldn’t remove it. A registered nurse applied the pad to the resident in a wheelchair, told the resident’s spouse to keep it on the resident for 20 minutes, and assumed the spouse would then remove the pad. A review of the resident’s clinical record found no physician’s order for a heat pad.
On May 8, the resident was transferred to a hospital for an unrelated reason and didn’t return to the facility, according to DPH.
Officials at the facility didn’t return a call seeking comment.
Meridian Manor Health & Rehabilitation Center in Waterbury was fined $3,060 after a resident suffered an allergic reaction after eating shellfish.
On March 9, the resident had red eyes, nausea and had a scratchy throat after a “fish lunch,” according to the citation. The resident was allergic to shellfish, but that information was missing from a dietary admission assessment. A registered nurse told investigators it was unclear why the allergy, which was in the resident’s medical record, wasn’t listed on the resident’s meal slip that was given to the dietary department.
An advanced practice registered nurse gave the resident Benadryl and tried to administer epinephrine, but the resident didn’t receive the latter because the device malfunctioned. According to DPH, the resident was taken to a hospital, intubated and sedated, and supported on mechanical ventilation for several days before returning to the facility March 14.
Officials at the facility didn’t return a call seeking comment.
