Waterbury Nursing Home Cited for Choking Death, Others Lapses

Written by Lisa Chedekel

A Waterbury nursing home has been cited by the state Department of Public Health in connection with the April death of a resident who choked on a meatball, while six other state nursing homes face fines for other instances of inadequate care.

Meridian Manor faces a $510 fine for failing to properly monitor a resident with intellectual disabilities who ordered take-out food from a local restaurant on April 29. The plan of care for the resident, who had choked once before while eating pork, called for intermittent meal supervision, some assistance with eating, and a “soft consistency” diet, the DPH inspection report says. The restaurant delivered ziti and meatballs to the resident without checking with staff, and the resident was found choking on the food and was rushed to the hospital, where intubation failed.

State inspectors found that the nursing home did not have a clear policy for the ordering and delivery of take-out food by residents, except for a sign that instructed that food delivered to the facility was to be checked by the nursing staff. After the incident, Meridian Manor took steps to educate staff members about food delivery and posted more signage about deliveries, the state report says.

Two southeastern Connecticut nursing homes also face fines for improper care, both related to residents developing pressure ulcers. Kindred Nursing & Rehabilitation Crossings West, in New London, faces a $510 fine for not taking proper steps to ensure that a resident’s heels were protected from potential pressure sores. The resident, who suffers from Alzheimer’s disease, depression and congestive heart failure, developed sores on both heels, the DPH report says.

Norwichtown Rehabilitation and Care Center, of Norwich, faces a $1,020 fine in connection with lapses in care involving two residents. The nursing home could not provide documentation that it properly treated a resident who developed a pressure ulcer on his or her heel. In the second case, the home was cited for failing to properly monitor a resident’s weight loss—specifically, a drop of 8.7 pounds, down to 88 pounds, in five days last November. The resident was discharged without being re-weighed, in violation of the facility’s policy, according to the state report.

Four other homes were cited for deficiencies in care:

• Village Green of Bristol, in Forestville, faces a $1,240 fine for lapses in care involving four residents. In one case, a resident reported that a nurse’s aide placed him or her on a bed pan and left for an hour, threatening that the resident would be left on the bedpan for the rest of the night. The resident reported the threat to another staff member, and the nurse’s aide was suspended and did not return to work, the state report says. Two other incidents involved residents who were injured when they were moved improperly, while the third involved lapses in care for a resident who developed a pressure ulcer.

• Ludlow Center for Health & Rehabilitation, in Fairfield, faces a $1,130 fine in connection with several lapses in care, including failing to care properly for a resident with a pressure sore, and a lack of proper “isolation” signage instructing staff and visitors to take precautions around several residents with MRSA or other infections. The nursing home subsequently took steps to ensure that precautions were in place for residents with drug-resistant infections, the state report says.

•Filosa for Nursing & Rehabilitation, in Danbury, faces a $690 fine for several instances of inadequate care, including failing to increase its supervision of a resident with dementia who wandered, smeared feces on furniture, and drank a bottle of perfume. The home also was cited for failing to care properly for several residents who developed pressure sores. In a separate citation, Filosa was fined $210 when staff were unable to show that a physician had reviewed the results of a resident’s lab tests for Dilantin levels.

•Rosegarden Health and Rehabilitation Center, in Waterbury, faces a $600 fine for three incidents, one in which a resident with dementia wandered out of the home when a WanderGuard security system was turned off. State inspectors found that the home did not have records that staff had checked the functioning of the WanderGuard system for at least two weeks in April. The resident was found in a rear parking lot, unharmed. The home also was cited for allowing a resident who was supposed to be given a ground-food diet to eat a piece of chicken, which the resident choked on and subsequently coughed up.