Three Connecticut nursing homes have been fined more than $1,000 each by the state Department of Public Health in connection with incidents in which residents broke a leg, developed pressure sores or were injured during a fall.
On April 8, Touchpoints at Farmington was fined $1,300 in connection with a dementia patient who broke a leg after getting agitated, DPH records show.
On Aug. 14, the resident had been found in a hallway in the early morning, with one nurse’s aide reporting that the resident had struck another resident, records show.
Two nurse’s aides put the resident back in bed and he or she became combative, kicking a wall, bed and table for five to 10 minutes until the aides reported hearing a “pop” or “snap,” records show.
The resident was hospitalized, and a radiologist reported that the broken leg was caused by blunt force trauma, adding that “this type of fracture is not spontaneous and/or pathological,’’ DPH’s citation states.
A registered nursing supervisor reported that he or she had not been told that the resident was combative until after the incident and did not know that the person had hit another resident until the nurse’s aide was interviewed several months later, records show.
The director of nursing services reported that the resident’s care plan, which called for intervention when the resident exhibited negative behavior, was not followed during the incident, state records show. The director also said the aides should have notified a nurse when the resident got agitated, records show.
Administrator John Zazzaro said he could not comment on the specific incident due to resident privacy. He said the home works with DPH annually to make improvements and it aims at “providing the highest quality of care practicable for each resident and patient” through “various quality improvement activities and oversight.”
On April 4, Apple Rehab Coccomo in Meriden was fined $1,160 in connection with one resident who had a pressure sore and who needed a splint and another resident who fell and sustained a cut on the head.
The first resident was in severe pain on March 26 from a pressure sore on the hand, which was clenched in a fist, DPH records show. The assistant director of nursing said the staff was supposed to assess the skin of residents and should have opened the resident’s hand to check the condition of the skin, DPH records stated.
Another employee said the resident had had a palm guard or splint while in the short-term care unit of the home but could not say what happened to it when the resident was transferred to the long-term care unit, records show.
Ann Collette, a spokeswoman for Apple Rehab, said the incident was an isolated occurrence, but because of it, a plan was implemented to have rehabilitation employees communicate the need to nurses of any devices for residents. Certified nurse’s aides were also educated to report any changes they see in a resident’s range of motion to a nurse so interventions can take place, she said.
State records said the resident with Alzheimer’s disease who fell Jan. 7 had fallen seven times in the home between March 2013 and January 2014. The resident fell backwards and hit his or her head on a chair after being left alone briefly in a bathroom, records show. The director of physical therapy said a nurse’s aide should have used a gait belt to assist the resident, records show.
Collette said the resident was not injured in the other falls. Due to the January fall, all certified nurse’s aides at the home were trained to use a gait belt when moving residents, she said.
On March 31, Bishop Wicke Health and Rehabilitation Center of Shelton was fined $1,020 in connection with a resident who developed a deep tissue injury on a heel.
The resident, who came to the home after surgery for a broken hip, developed the injury in February, records show. State officials concluded that the home’s records failed to document whether the area of the foot was monitored or that the resident’s heels were properly “offloaded” when he or she was put in or taken out of bed, records show.
Debra Samorajczyk, Bishop Wicke’s administrator, said the home values DPH’s guidance and uses its inspection reports as a valuable tool to improve care.
“We take every opportunity when the state visits us as a chance to update and educate our staff on new protocols in order to keep current with best practices and maintain our optimum standards of care,” she said.
