Citations in Connecticut
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Connecticut.
Statistics for Connecticut (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Connecticut
- Educated all nursing staff on medication reconciliation and diabetes management (J - F0760 - CT)
Failure to Prevent Significant Medication Error During Readmission
Penalty
Summary
A significant medication error occurred when a resident was readmitted to the facility following a hospital stay. During the readmission process, the responsible RN discontinued all previous medication orders in the electronic medical record (EMR) and then renewed all discontinued orders, including some that were not present on the hospital discharge documents and had been discontinued nearly a year prior. This included Levemir insulin, which was not ordered by the readmitting provider and was not listed as an active order on the hospital discharge summary. Additionally, oral anti-diabetic medications that were supposed to be stopped per the hospital discharge documents were also renewed and administered. Multiple nursing staff administered Levemir insulin to the resident over several days without obtaining required blood glucose checks prior to administration, as specified in the provider's order. The provider's order also directed that insulin should be held if blood sugar was less than 80, but this was not followed. The resident's blood sugars were not monitored from the time of readmission until the resident experienced a significant change in condition. When the resident became unresponsive and exhibited abnormal movements, staff failed to immediately check blood glucose, delaying identification of severe hypoglycemia. Interviews and documentation revealed that the medication transcription and verification process was not followed according to facility policy. The nurse practitioner did not review the active medication list in the EMR during post-readmission visits, and the third shift nurse did not verify the orders for accuracy. The facility's orientation materials for agency staff did not include clear procedures for medication reconciliation or order transcription during admission or readmission. As a result, the resident received medications that were not ordered, and critical monitoring steps were missed, leading to a hypoglycemic event requiring emergency intervention.
Removal Plan
- Ensure Resident #3 receives all medications according to provider order
- Educate all nursing staff on medication reconciliation and diabetes management
- Audit all residents prescribed insulin
- Audit all readmission orders
Latest Citations in Connecticut
Two cognitively intact residents requiring ADL assistance were subjected to verbal abuse by nursing assistants, who yelled and used profanity when one resident requested help with a bedpan. The staff member left without providing care, and both residents' accounts were consistent in describing the mistreatment. Facility investigation confirmed that the actions violated the abuse policy prohibiting verbal abuse and mistreatment.
A resident who required a mechanical lift and two-person assistance for transfers was instead transferred by a single nurse aide without the lift, resulting in a fall and ankle fractures. Additionally, several doors on the locked memory care unit, including those to rooms containing hazardous materials, were found unsecured, contrary to facility policy requiring a secure environment for resident safety.
A resident with severe cognitive impairment and mobility dependence was physically abused by another resident with a history of aggression and psychiatric diagnoses. The aggressor, who had previously refused medications and had prior altercations, slapped the victim in the hallway, resulting in facial redness. The incident was witnessed by staff and a non-staff member, and the facility failed to prevent the abuse as required by policy.
Two residents dependent on staff for toileting and personal hygiene did not receive required incontinent care during an overnight shift, as documented by care records and resident interviews. Both reported that a nurse aide failed to provide care or assist with repositioning, and the call bell was not accessible for one resident. Facility documentation confirmed the lack of care provided, in violation of established care plans and policies.
A resident with severe cognitive impairment and a history of falls was witnessed by staff to fall and strike their head, resulting in altered mental status and inability to obtain vital signs. Despite these symptoms, the supervising RN directed staff to move the resident from the floor to a wheelchair and then to bed, rather than waiting for EMS as required by protocol. The resident was later transferred to the hospital and expired a few hours after the incident. Staff interviews and documentation confirmed that the resident should not have been moved following the fall.
The facility did not promptly report incidents of suspected abuse, neglect, and injuries of unknown origin to the State Agency as required. In separate events, a resident was found with an unexplained eye injury, two residents were involved in a physical altercation, and four residents did not receive timely incontinent care. In each case, staff failed to notify the State Agency within the mandated timeframe, despite facility policy requiring immediate reporting.
A resident with severe cognitive impairment and incontinence did not receive timely incontinent care, and no RN assessment was performed after the delay was identified. An APRN evaluated the resident's skin nearly two days later but failed to document the visit until 17 days afterward, contrary to facility policy requiring timely documentation.
The facility did not promptly report multiple allegations of abuse involving residents with cognitive and physical impairments to the Administrator, State Agency, or Police as required by policy. Incidents included resident-to-resident aggression and a claim of a staff member pushing a resident, with delays or failures in documentation, notification, and escalation by staff and resident representatives.
The facility did not promptly investigate or report multiple allegations of abuse involving residents with cognitive impairments and behavioral concerns. Staff failed to document incidents, notify administration, or remove involved personnel as required by policy, resulting in delayed reporting to the State Agency and incomplete investigations.
A resident with a history of a left tibia fracture and chronic pain was given a 50mg dose of Morphine Sulfate Oral Solution instead of the prescribed 5mg dose, due to administration of the wrong concentration. The error occurred when an RN supervisor provided the medication from a locked cabinet, bypassing standard verification procedures, and an LPN administered it without checking the label against the order. No adverse effects were observed in the resident at the time.
Failure to Protect Residents from Verbal Abuse by Nursing Assistants
Penalty
Summary
Two residents, both cognitively intact and requiring assistance with activities of daily living, experienced verbal abuse from nursing assistants during the evening shift. One resident, with diagnoses including depression and anxiety, requested assistance with a bedpan by using the call bell. When a staff member entered the room, she began yelling and using profanity, accusing the other resident of ringing the bell excessively. The resident who had called for help clarified it was their request, but the staff member did not respond and left without providing care. The second resident, who has congestive heart failure and a pressure ulcer requiring wound management, corroborated the account, stating that the staff member yelled, swore, and left the room without assisting the first resident. The incident was reported by the first resident to the facility administrator the following day. Both residents were interviewed as part of the facility's investigation, and their statements were consistent regarding the verbal abuse and lack of care provided during the incident. Staff interviews revealed that the nursing assistant involved denied the allegations, citing being overwhelmed by workload, while another staff member reported hearing similar language from a different nursing assistant but could not confirm the context. The facility's investigation substantiated the allegations of verbal abuse based on resident interviews and staff statements. Facility documentation and policy review confirmed that the actions of the nursing assistants violated the facility's abuse policy, which prohibits any form of mistreatment, including verbal abuse. The policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents. The failure to provide care and the use of profane, aggressive language toward the residents constituted mistreatment and a breach of the residents' right to be free from abuse.
Failure to Follow Transfer Orders and Secure Memory Care Unit
Penalty
Summary
A deficiency occurred when a resident with a history of transient cerebral ischemic attack, morbid obesity, and difficulty walking was not transferred according to physician orders. The resident was assessed as moderately cognitively impaired, non-ambulatory, and required the use of a mechanical lift (Sarita) with the assistance of two staff members for transfers. However, the nurse aide care card contained conflicting instructions, and a nurse aide attempted to transfer the resident alone without the mechanical lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent fractures to the right ankle, confirmed by x-ray. The nurse aide reported confusion regarding the care card instructions and did not seek clarification before proceeding with the transfer. Additionally, the facility failed to ensure that all appropriate doors were secured on the locked memory care unit. Observations revealed that the shower room contained potentially hazardous items and was not secured, the dentist office door was propped open, and the soiled utility room door with a keypad lock had been bypassed and was not locked. The soiled utility room contained bottles of cleaning solution, and staff were unaware that these doors were unsecured. The maintenance director demonstrated how the keypad could be bypassed and acknowledged the need for a more secure lock. Interviews with staff confirmed that the unsecured doors and access to hazardous materials were not in accordance with facility policy, which required all doors on the secured memory care unit to be locked for resident safety. The facility's policy for the memory care unit emphasized maintaining a secure environment to ensure the safety and well-being of residents, but this was not followed at the time of the survey.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with vascular dementia and schizophrenia, who was severely cognitively impaired and dependent for wheelchair mobility, was physically abused by another resident diagnosed with dementia, paranoid schizophrenia, and schizoaffective disorder. The incident occurred when the second resident, who had a history of physical aggression and prior altercations, approached the first resident in the hallway and slapped the left side of their face. This act was witnessed by a non-staff member and a nursing assistant, with the latter observing the aggressor slap the victim a second time. The victim was found with facial redness as a result of the incident. Prior to the event, the aggressive resident had refused medications and was on a waitlist for in-patient psychiatric evaluation, with ongoing psychiatric follow-up and 15-minute checks in place. Despite a documented history of similar altercations, the facility failed to prevent the physical abuse, as required by their abuse policy, which prohibits residents from being subjected to abuse by anyone, including other residents. The facility's documentation and staff interviews confirmed the physical contact and the resident's history of aggression, but did not consider the contact willful.
Failure to Provide Required Incontinent Care and Neglect of Dependent Residents
Penalty
Summary
Two residents who were dependent on staff for toileting and personal hygiene did not receive the required incontinent care during an overnight shift. Both residents had care plans directing staff to provide incontinent care every two hours and as needed, to keep them clean and dry, and to ensure the call bell was within reach. Documentation and interviews revealed that a nurse aide failed to provide this care from the evening through the following morning, with no evidence of toileting hygiene being performed during the overnight hours. One resident, with diagnoses including peripheral neuropathy and morbid obesity, reported that after being put to bed in the evening, no staff entered the room to provide care or assist with toileting, and the call bell was not accessible. The resident was found soaked in the morning by the day shift staff. The other resident, with osteoarthritis and a history of recurrent urinary tract infections, similarly reported not receiving any care after a certain time in the evening, and that the nurse aide refused to assist with repositioning in bed, instructing the resident to do it independently despite their dependency. Facility documentation, including nurse notes and incident reports, corroborated the residents' accounts, and point of care records lacked evidence of overnight care being provided. The facility's policies require prevention of neglect and the provision of care as outlined in residents' care plans, but these were not followed during the incident in question.
Failure to Follow Protocol After Resident Fall with Head Injury
Penalty
Summary
Staff failed to follow professional standards of care after a resident with dementia, heart failure, and severe cognitive impairment experienced a witnessed fall with a head injury. The resident, who was known to be at risk for falls and had a history of recent illness, was observed by a nurse aide to become dizzy, spin, and fall, striking their head on the floor. Following the fall, the resident exhibited altered mental status, was unable to follow commands, and staff were unable to obtain vital signs. Despite these significant changes in condition and the presence of a head injury, the supervising RN directed staff to move the resident from the floor into a wheelchair and then into bed, rather than leaving the resident in place and awaiting EMS as per standard protocols for suspected head or spinal injury. Multiple staff, including an LPN and the APRN, later acknowledged that the resident should not have been moved given the circumstances. Facility policy and medical references reviewed also indicated that residents with head injuries and neurological compromise should not be moved and should be referred immediately for emergency care. The resident was eventually transferred to the hospital by EMS after oxygen was applied, but expired a few hours later. Documentation and interviews confirmed that the decision to move the resident was made by the RN, and that other staff present did not question this directive, despite recognizing it was not consistent with best practice or facility policy for post-fall care involving head injury and altered mental status.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, and injuries of unknown origin to the State Agency as required by regulation. In one instance, a resident with hemiplegia and multiple comorbidities was found with discoloration around the left eye, which was identified as an injury of unknown origin. Although the injury was assessed by nursing staff and the responsible party and provider were notified, the incident was not reported to the State Agency. Both the LPN and the Nursing Supervisor acknowledged that the injury should have been classified as an injury of unknown origin and reported, but this did not occur. In another case, a resident-to-resident altercation occurred when one resident, with a history of agitation and aggression, punched another resident in the face in the dining room. The incident was witnessed and reported to an LPN, who assessed the involved residents and notified the provider and responsible party. However, the altercation was not reported to the State Agency until over 17 hours after the event, well beyond the required reporting timeframe. The DON stated that the delay was due to not being made aware of the incident until the following day. Additionally, four residents with varying degrees of cognitive impairment and incontinence did not receive timely incontinent care. The incident was identified by an LPN, who found multiple residents in need of care, and it was later determined that care had not been provided for an extended period. Although the supervisor was made aware of the neglect, the State Agency was not notified until nearly two days after the facility became aware of the situation. Facility policy and staff education materials indicated that such allegations should be reported immediately to supervisors and to the State Agency within two hours, but this protocol was not followed in these cases.
Failure to Timely Document APRN Visit and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure complete and timely documentation in the medical record for a resident with hemiplegia, aphasia, and severe cognitive impairment. The resident required assistance with activities of daily living (ADLs) and was always incontinent. On a specific date, an LPN identified that the resident had not received timely incontinent care, and this was documented in an incident report. Despite the identification of omitted care, no RN assessment was performed from the time the issue was discovered until the end of the shift. Additionally, an APRN evaluated the resident's skin condition nearly two days after the omitted care was identified, but did not document the visit until 17 days later as a late entry. Both the APRN and the Director of Nursing confirmed that the note should have been written at the time of the visit, in accordance with the facility's documentation policy, which requires documentation at the time of service or by the end of the shift. The failure to document the APRN visit in a timely manner resulted in an incomplete and inaccurate medical record for the resident.
Failure to Timely Report Alleged Abuse and Incidents to Authorities
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft to the Administrator, State Agency, and Police as required by facility policy for three residents reviewed. In one case, a resident with cerebral palsy and adjustment disorder reported that another resident with Alzheimer's disease grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or reported to the appropriate authorities until the surveyor brought it to the attention of the Director of Nursing Services (DNS). The DNS admitted to delaying the report to the State Agency and not notifying the police, contrary to facility policy, and was unaware of the incident until informed by the surveyor. Interviews revealed that the social worker and charge nurse were also unaware or did not report the incident, and the resident's representative had not been informed. Another resident with dementia and depression alleged that a nurse aide pushed them into the bathroom, but was unable to identify the aide. The resident reported the incident to their representative, who did not escalate the concern, believing it may have been a misunderstanding. The charge nurse was aware of the resident's ongoing complaints about a mean and bossy aide but did not report these concerns to administration. When the resident later told an RN about being pushed, the RN conducted an informal investigation but did not report the incident to the DNS, nor did she document the event or collect staff statements. The DNS only became aware of the allegation when notified by the surveyor and subsequently delayed reporting to the State Agency. A review of facility documentation, including care plans and nursing notes, failed to show any record of the alleged incidents for the residents involved. The facility's abuse policy requires immediate reporting of any alleged or witnessed abuse to the nursing supervisor, department heads, administrator, police, and state authorities within two hours. The failure to follow these procedures resulted in delayed or absent reporting and documentation of abuse allegations, as well as a lack of timely notification to the appropriate authorities.
Failure to Timely Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to respond appropriately to allegations of abuse involving three residents. In the first case, a resident with cerebral palsy and anxiety reported that another resident with Alzheimer's disease and agitation had grabbed their neck and pushed their wheelchair, leading to a retaliatory act where the first resident ran over the other's feet. This incident was not documented in the care plans or nursing notes, and the Director of Nursing Services (DNS) was unaware of the event until informed by a surveyor. The incident was not reported to the State Agency immediately, and the investigation summary was delayed. Additionally, the involved residents' representatives were not notified, and staff members who were aware of the incident did not escalate it to administration as required by policy. In another instance, a resident with dementia and depression alleged that a nurse aide had pushed them into the bathroom. The resident was unable to identify the aide, but consistently described the aide as mean and bossy. The allegation was not reported to the DNS or administration by the staff who were aware of the resident's concerns. The resident's representative also failed to report the concern, believing it may have been a misunderstanding. When the DNS was finally informed by a surveyor, the incident had not been documented in the care plan or nursing notes, and the staff member involved was not identified or removed from duty as required by facility policy. Across both cases, the facility did not follow its abuse policy, which requires immediate initiation of a thorough investigation, removal of the involved staff member, and timely reporting to the State Agency. Documentation was lacking, and there were delays in both internal and external reporting. Statements from involved staff were incomplete or missing, and the required investigation steps were not followed promptly or thoroughly.
Significant Medication Error Due to Incorrect Morphine Sulfate Dose
Penalty
Summary
A significant medication error occurred when a resident with a history of a displaced spiral fracture of the left tibia and chronic pain was administered an incorrect dose of Morphine Sulfate Oral Solution. The physician's order specified Morphine Sulfate 10mg/5ml, with a dose of 2.5 ml by mouth every 4 hours as needed for moderate pain. However, the resident was given a 50mg dose instead of the ordered 5mg dose, due to the administration of Morphine Sulfate 100mg/5ml solution rather than the prescribed concentration. This error was identified after the medication was administered, and the resident was closely monitored, with no apparent adverse effects noted at the time of evaluation. The error was facilitated by a breakdown in medication storage and verification procedures. The Morphine Sulfate 100mg/5ml was not stored in the Omnicell automated dispensing cabinet due to a barcode issue, and was instead kept in a locked cabinet in the nursing supervisor's office. On the day of the incident, the RN supervisor removed the medication from the locked cabinet and provided it to an LPN without verifying the medication order or the concentration of the medication. The LPN, in turn, did not check the label on the medication against the physician's order before administration, assuming it was correct. Facility policy required a three-way check to compare the medication to the medication administration record and the prescription label, as well as verification of the correct medication and dose prior to administration. Both the RN supervisor and the LPN failed to follow these procedures, resulting in the administration of the incorrect dose. The incident was documented as a medication administration error, as the resident received a different dosage than specified by the original order.
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