Connecticut DPH Fines Several Nursing Homes for Negligence Regarding Incidents
The Connecticut Department of Public Health (DPH) recently fined three nursing homes related to a number of deficiencies that occurred from March 2018 through January 2019. The fines for deficiencies cited involved these incidents:
- Four residents’ testing positive for cocaine use—one of residents was found on the floor unresponsive and sent to the hospital. The nursing home repeatedly failed to follow physician’s instructions regarding consecutive three-day searches for cocaine and failure to implement interventions to prevent recurrence. A nurse aide was fired for providing the cocaine to a resident who shared it via a one-dollar bill with three other residents. The facility was fined $1,680.
- A resident at risk for developing pressure ulcers was found with stage 2 and 3 pressure sores on his/her heels. The facility did not enter the physician’s treatment orders obtained when the ulcers were first noted until five days later. Those orders instructed staff to clean the resident’s heels with saline and to apply an ointment, and no other preventive measures were implemented. The facility was fined $6,420. When contacted, the facility reported it provided additional staff education and training and also submitted a plan of correction to the state.
- One facility was fined $7,340 for several violations that included a resident with psychosis and anxiety who experienced 14 unwitnessed falls over an 11-month period in which the resident sustained injuries, one of which required surgery. Another resident at this facility developed a stage 2 pressure ulcer because the facility’s staff failed to take preventive measures of repositioning and helping the resident with mobility. Still another resident requiring a mechanical lift for transfers got his/her leg trapped under the lift, resulting in a broken left hip which the nursing aides failed to report to the nurses.
Only one of the three facilities responded to media inquiries about the fines and the citations.
Compliance Perspective
Failure to enter physician’s orders into residents’ records and to follow those orders, failure to implement a comprehensive risk fall assessment resulting in unwitnessed falls and injuries, and failure to report a resident accident with significant injury may all be considered abuse and neglect and deemed provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures regarding receiving and implementing physician orders, pressure ulcer preventive measures, comprehensive risk assessment completion with intervention, and mandatory reporting of resident incidents.
- Train staff about obtaining and implementing physician orders and documenting implementation of those orders. Also, provide training on abuse and neglect in failing to prevent vulnerable residents from developing pressure ulcers and reporting of any incident/accident involving residents.
- Periodically audit patient records to determine if physician’s orders are recorded accurately and being followed. Monitor for implementation of pressure ulcer prevention measures and appropriate fall prevention and response actions.
