Orchard Grove Specialty Care Center in Uncasville was fined $3,480 after a resident with multiple sclerosis developed severe blisters following a moist-heat treatment.
On April 7, the resident had a fluid-filled blister that measured 8 by 6 centimeters on the right shoulder, as well as a red rash on the left shoulder. Two days later, the resident had “multiple areas of large fluid-filled blisters” on both shoulders that were oozing, according to the citation.
An investigation found the blisters were caused by a treatment administered by an occupational therapist during which moist heat was applied with hydrocollator packs. The therapist said the resident didn’t complain of any discomfort, but the resident was at risk for skin injury due to sensory impairment, according to DPH.
The therapist had not gotten a physician’s order for the moist heat application, and the facility’s policy failed to require staff to do so, according to the citation.
Officials at the facility didn’t return a call seeking comment.
Geer Nursing and Rehabilitation in Canaan was fined $3,060 after a resident suffered leg fractures in a fall.
On Jan. 16, two aides had just transferred the resident into a wheelchair from a Hoyer lift and leaned the resident forward to remove a lift pad, DPH said. The resident’s legs slipped and staff were unable to stop the fall.
At a hospital, the resident was diagnosed with fractures in the left knee, tibia and fibula, as well as a broken right femur. An investigation found one of the aides involved was a new employee at the facility and had not been educated and/or observed on mechanical lift transfers. According to the citation, a registered nurse should have been in the room to supervise the aide.
“Geer Nursing and Rehabilitation takes the health and safety of its residents very seriously. The recent violation and fine is the result of an isolated incident and not indicative of the quality care we provide daily,” said Administrator Robert Powers. “We have performed an internal review of our processes and feel strongly that our corrective actions will prevent similar events from occurring in the future.”
Abbott Terrace Health Center in Waterbury was fined $2,600 after a resident with dementia wandered out of the facility.
The resident, who was a known escape risk and was on a locked dementia floor, left the facility on June 3, according to DPH. Staff, who were supposed to check on the resident every shift, noticed the resident missing at 4 p.m.; police subsequently called at 4:20 p.m. saying the resident had been found walking along a road.
The resident was taken to a hospital and received one suture for a hand laceration, the citation said.
The resident had previously tried to leave the on seven separate days between April 29 and June 3, according to DPH. On the day the resident left, a licensed practical nurse didn’t do rounds at the beginning of her 3 p.m. shift because she didn’t know she was supposed to.
An investigation found a staff member had exited through a door and either didn’t securely close it afterwards or make sure that all residents were accounted for in the facility. Despite the resident wearing a “roam alert band,” multiple staff said they didn’t hear any door alarms sound, according to the citation.
Officials at the facility didn’t return a call seeking comment.
Apple Rehab Avon was fined $1,330 for two instances in which staff did not follow policies.
On May 20, a nurse aide failed to immediately report overhearing a resident on the phone considering suicide. According to the citation, the incident happened around noon but the aide didn’t report it until 3:15 p.m. A review of the resident’s medical record failed to show that a supervisor assessed the resident or that the resident had been placed on close observation after being overheard.
On May 10, a resident with muscular dystrophy and anxiety opened the door to a dining room, exited the facility in an electric wheelchair and rammed through a gate into a parking lot. When staff tried to help, the resident threatened them with scissors, according to DPH.
Police and an ambulance were called, but the resident remained at the facility. An investigation found the facility failed to place the resident on one-on-one observation after the incident, violating policy, according to the citation.
Officials at the facility didn’t return a call seeking comment.
