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)
Latest Citations in Connecticut
The facility did not maintain consistent records of required monthly water flushes for showers, tubs, faucets, and eyewash stations as outlined in its water management plan. Although some flushing was performed, documentation was lacking due to staff oversight and extended absences, and the water management policy did not specify preventative measures. This resulted in a deficiency related to the facility's infection prevention and control program.
Surveyors found expired medications, undated opened containers, and staff personal items improperly stored in two medication rooms. An LPN confirmed responsibility for discarding expired medications and dating items, but some items were not dated or removed. The DON stated that all medications should be labeled and personal items stored in designated staff areas, in accordance with facility policy.
Two out of three ice machines were found with a black substance buildup inside, despite logs and tags indicating monthly and annual cleaning had been performed. Observations and interviews with environmental services staff confirmed the unsanitary condition, and facility policy requiring daily inspections and regular cleaning was not followed.
A resident with multiple medical conditions was discharged after not returning from a leave of absence, but was not provided with written notice of discharge or informed of their right to appeal. Facility staff did not document that the resident wished to be discharged or that a medical provider was involved in the decision, and interviews confirmed that required notifications were not given.
A resident with severe cognitive impairment and on hospice care did not have a comprehensive end-of-life care plan developed or revised for an extended period, and the facility failed to coordinate with the hospice provider or obtain timely hospice certification paperwork. The only intervention documented was to honor the resident's and family's wishes, and the hospice provider was not included in care plan meetings, contrary to facility policy.
A resident with quadriplegia and a sacral pressure ulcer did not have their care plan updated to reflect changes in wound status and treatment, including the discontinuation of PICO wound therapy and progression to a stage 4 ulcer. The care plan continued to list outdated interventions and did not include the resident's preferences or documentation of turning and repositioning, contrary to facility policy.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A resident with cognitive impairment and behavioral health diagnoses alleged rough care by a CNA. The facility notified the physician and family and conducted an internal investigation, but did not notify local law enforcement as required by policy, citing the resident's history of similar accusations. The incident was ultimately determined to be unsubstantiated.
A resident with a central line for antibiotic therapy did not receive IV flushes in the correct order as per physician orders and facility policy. An LPN administered heparin before saline after disconnecting the antibiotic, instead of following the required saline-then-heparin sequence. The facility's SASH protocol and IV management policy were not followed, as confirmed by staff interviews and record review.
Failure to Document and Implement Water Flushing per Water Management Plan
Penalty
Summary
The facility failed to maintain records of monthly water flushes as required by its water management plan. An environmental assessment identified risk areas for opportunistic pathogens and recommended flushing uncommonly used tubs, showers, and faucets for 3 to 5 minutes, with documentation to be kept in the service records. The water management plan also required monthly flushing of eyewash stations. Despite these requirements, a review of facility documents revealed that the last documented water flushing occurred several months prior, and there was no consistent documentation of flushing activities for tubs, sinks, or showers. The Director of Physical Plant acknowledged performing the flushes but admitted to not always documenting them due to other responsibilities and periods of extended leave. During the Director's absence, the Special Projects Supervisor covered some duties but did not consistently document or recall all required flushing activities. Additionally, the facility's water management plan policy lacked specific preventative measures to prevent the growth of opportunistic pathogens, and meeting minutes indicated that flushing documentation was not reviewed during water plan meetings. While water testing for opportunistic pathogens was completed and results were negative, the facility did not have a reliable system in place to ensure and document that all required water flushing tasks were performed according to the plan. This lack of documentation and inconsistent implementation of the water management plan's requirements led to the identified deficiency.
Expired and Unlabeled Medications, Improper Storage of Personal Items in Medication Rooms
Penalty
Summary
Surveyors observed that in two of four medication rooms, expired medications and biologicals were not discarded as required, and some items were not labeled with the date they were opened. Specifically, in the Bliss unit medication room, expired Polydent Antibacterial Denture Cleaner and hand cream were found, as well as an open box of denture cleaner and an open container of Thick and Easy powder, both lacking the date of opening. Zinc tablets with a valid expiration date were also present, but the open items were not properly labeled. An LPN confirmed that all nurses are responsible for discarding expired medications and dating items when opened, but was unsure why some items were not dated. The hand cream was believed to be a staff member's personal item. In the Reflection unit medication room, an open container of Thick and Easy powder was also found without a date of opening. The Director of Nursing Services (DNS) confirmed that all medications should be labeled and dated once opened, and that personal items for staff should be stored in designated areas such as lockers or closets, not in medication rooms. Facility policies require expired medications to be removed and destroyed, and all opened containers to be dated, but these procedures were not followed in the observed instances.
Ice Machines Not Maintained in Sanitary Condition
Penalty
Summary
Surveyors observed that two out of three ice machines in the facility were not maintained in a sanitary condition. Specifically, a black substance was found built up on the inner edges of the Unit 1 ice machine during an inspection. Documentation attached to the machine, including a cleaning schedule log and a service provider label, indicated that the last recorded cleaning was in June, and annual maintenance was performed in March. However, the presence of visible buildup suggested that cleaning and sanitization were not performed as required. Further observations and interviews with the Physical Plant Director and the Regional Director of Environmental Services confirmed the black buildup inside the ice machines on both Unit 1 and Unit 2. Although each machine had tags indicating yearly maintenance and monthly cleaning checklists with staff initials, the black substance was still present. The Regional Director acknowledged that housekeeping was responsible for cleaning the machines and that the buildup was unacceptable. Facility policy required daily visual inspections, monthly cleaning, and annual thorough cleaning and sanitization, but there was no evidence of prior staff training for this task, and the required standards were not met.
Failure to Provide Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide written notice of discharge and did not inform a resident of their right to appeal prior to discharge. The resident, who had diagnoses including anxiety, heart failure, and dysphagia, was cognitively intact and required varying levels of assistance with activities of daily living. The resident went on a leave of absence (LOA) with a responsible party, with the expectation to return on a specified date. Documentation showed that the resident and responsible party communicated changes in the return date, but there was no indication that the resident expressed a desire to be discharged or that a medical provider was involved in the discharge decision. When the resident did not return at the agreed-upon time, facility staff informed the responsible party that the resident was considered discharged against medical advice (AMA) for violating LOA protocol. There was no evidence that a written discharge notice was provided or that the resident was informed of their right to appeal the discharge. Interviews with the responsible party and social worker confirmed that neither written notification nor information about appeal rights was given prior to the discharge, and the facility's documentation did not reflect involvement of a medical provider in the discharge process.
Failure to Coordinate and Document Hospice Care Planning
Penalty
Summary
A deficiency was identified in the facility's management of hospice services for a resident with severe cognitive impairment and a diagnosis of unspecified dementia with behavioral disturbance. The resident was admitted with advanced directives specifying do not resuscitate, do not intubate, do not hospitalize, and to provide comfort care. Despite being on hospice care, the only intervention documented in the care plan was to honor the resident's and family's wishes, with no further revisions or comprehensive end-of-life care planning. The facility failed to develop a care plan that coordinated services between the hospice provider and the facility, and did not initiate an end-of-life (hospice) care plan for over 95 days after hospice admission. Additionally, the facility did not ensure timely receipt of hospice renewal orders and plans of care, as there was no 90-day re-certification paperwork available after a certain date. The hospice provider was not routinely invited to participate in care plan meetings for hospice residents, and the required documentation for hospice certification periods was only obtained after surveyor inquiry, well after the resident had been on hospice services. These actions and omissions were not in accordance with the facility's own policy, which required comprehensive, coordinated care planning in collaboration with the hospice agency.
Failure to Update Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a pressure ulcer was updated to accurately reflect the resident's current status and treatment interventions. The resident, who had diagnoses including a sacral pressure ulcer and quadriplegia, was initially care planned for being at risk for pressure ulcers with interventions such as pressure redistribution devices, skin protectants, and daily skin evaluations. The care plan also noted an unstageable pressure ulcer with an intervention for wound clinic services and PICO wound therapy. However, after the PICO therapy was discontinued and the wound progressed to a stage 4 ulcer, the care plan was not updated to reflect these changes. The intervention to use PICO therapy remained in the care plan even though it had been discontinued two months prior, and the care plan continued to list the ulcer as unstageable rather than stage 4. Further, the resident's preferences regarding time out of bed and repositioning, as well as the actual wound care interventions being provided, were not reflected in the care plan. The facility wound nurse confirmed that the care plan was not current and that documentation of turning and repositioning was not included, despite facility policy requiring individualized care plans for residents with pressure ulcers. The policy also required that turning and repositioning be documented in the care plan and that licensed nurses update the care plan as necessary, which was not done in this case.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency were not provided in the report.
Failure to Notify Law Enforcement After Abuse Allegation
Penalty
Summary
The facility failed to notify local law enforcement following an allegation of abuse involving a resident with dementia, paranoid personality disorder, anxiety, and depression. The resident, who had moderately impaired cognition and required significant assistance with daily activities, alleged that a certified nurse aide provided rough care during an evening shift. The incident was documented on a State of Connecticut Reportable Event form, and the physician and the resident's family were notified. The facility administrator initiated an internal investigation by interviewing staff the following day. Despite the facility's abuse policy directing that allegations be reported to local law enforcement when appropriate, the police were not notified. The administrator stated that the decision not to contact law enforcement was based on the resident's history of accusatory behaviors and frequent calls to the police department. The internal investigation concluded that the allegation was unsubstantiated, but the required notification to law enforcement was not made as outlined in facility policy.
Improper Administration of IV Flushes Following Antibiotic Therapy
Penalty
Summary
Licensed staff failed to administer saline and heparin intravenous flushes according to facility policy and standard of care for a resident with a central line receiving antibiotic therapy. The resident, who was cognitively intact and had an artificial hip joint infection with an open hip wound, had physician orders specifying the use of a central line for intermittent infusions. The orders directed that the central line be flushed with 10 mL of saline before medication administration, and after medication administration, flushed with 10 mL of saline followed by 5 mL of heparin. However, observation revealed that an LPN flushed the central line first with 5 mL of heparin and then with 10 mL of saline, contrary to the prescribed order and facility protocol. Interviews with the LPN and the Director of Nursing Services (DNS) confirmed that the facility uses the SASH protocol (Saline, Antibiotic, Saline, Heparin) for central line maintenance, which was also reflected in the facility's IV management policy. The LPN admitted to possibly misreading the order and was unsure why the sequence was reversed. The DNS was also unable to explain the deviation from protocol. The deficiency was identified through observations, staff interviews, and review of facility policy and resident records.
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
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