Connecticut Baptist Homes, Inc

Inspectors wroteBased on the residents' medical records, facility documentation review, and interviews, it was determined that the facility failed to ensure that residents were free of significant medication errors. Specifically, the facility failed to administer correct medication to Resident #1 which led to harm and resulted in hospitalization with consequences.

Inspectors wroteBased on observations, clinical record review, facility policies, and staff interviews, the facility failed to timely identify and respond to significant weight loss for 2 of 6 residents (Residents #3 and #26). The facility did not complete physician ordered weekly weights, did not obtain required reweights after weight loss of 5 pounds or greater per policy, failed to notify providers and the dietitian of documented significant weight loss, and did not implement or provide ordered nutritional supplements. These failures resulted in delays in assessment and intervention, allowing both residents to experience continued, preventable weight loss over multiple weeks.

Inspectors wroteBased on observation, interviews, and review of facility policy for 2 of 2 medication rooms, the facility failed to ensure expired supplies were discarded and failed to ensure the medication cart was secured when staff were not in attendance.

Inspectors wroteBased on interviews, observations in the Dietary department and facility policy, the facility failed to ensure various food items were labeled with the date opened/expiration date, failed to ensure items were not stacked when wet, failed to identify plates coming from the dishwasher were clean, and failed to take freezer temperatures in 2 of 2 nourishment rooms.

Inspectors wroteBased on interviews, review of facility policy and observations of resident bathrooms on 2 of 2 nursing units, the facility failed to ensure personal care items were properly labeled, covered, and stored according to facility policy and in a manner to provide a clean environment.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for 2 of 6 residents (Resident #3 and Resident #26) reviewed for nutrition, the facility failed to ensure timely notification of a significant weight loss to either the physician, Dietician or responsible party.

Inspectors wroteBased on clinical record review, interviews, and facility policy for 1 of 3 sampled residents (Resident #9) reviewed for accidents, the facility failed to complete neurological assessments after multiple unwitnessed falls, per facility policy.

Inspectors wroteBased on observations, review of the clinical record, facility policy and interviews for 1 of 3 residents observed utilizing an air mattress (Resident #31), the facility failed to ensure the air mattress was set according to physician orders. Additionally, for 1 of 2 sampled residents (Resident #45) reviewed for edema, the facility failed to complete weekly weights after readmission to the facility, per the physician order.

Inspectors wroteBased on observations, review of the clinical record, facility policy and interviews for the only sampled resident (Resident #6) reviewed for positioning and mobility, the facility failed to apply a left upper extremity splint per the physician's order for a resident with a hand contracture.

Inspectors wroteBased on observation, review of the clinical record, facility policy and interviews for the only sampled resident (Resident #6) reviewed for positioning and mobility, the facility failed to complete a mechanical lift transfer with 2 staff members.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #42, 9 and 7), reviewed for accidents, for Resident #42 who had severely impaired cognition, a history of falls and was at high risk for elopement, the facility failed to monitor and accurately document the residents location in the facility every 15 minutes according to the plan of care which resulted in the resident being able to exit the facility (elope) unsupervised. These failures to properly monitor and accurately document the resident's location in the facility allowed the resident to elope the facility and resulted in a finding of Immediate Jeopardy. [...]

Inspectors wroteBased on review of facility documentation, facility policy, and interviews the facility failed to ensure that an accurate record of an effective training program for all staff was maintained.

Inspectors wroteBased on review of facility documentation, facility policy, and interviews reviewed for training requirements the facility failed to ensure that an accurate record of continuing nurse aide competence of no less than 12 hours per year, including dementia management training and resident abuse prevention training, was maintained. Upon the survey team's request for documentation of the completion of 12 hours of nurse aide annual in-servicing and competency training, the facility was unable to provide sufficient documentation, including completed and signed Annual Inservice Education Fair 12/11/23 through 12/29/23 packets and competency forms. Interview with the Administrator on 7/8/24 at 11:25 AM identified that the facility was unable to locate staff competency forms and tracking documentation supporting the required annual 12-hour nurse aide training. [...]

Inspectors wroteBased on review of the clinical record, facility policy, and interviews for 1 of 4 residents (Resident #10) reviewed for accidents, the facility failed to complete neurological vital signs after an unwitnessed fall, and for the only sampled (Resident #54) reviewed for a non-pressure skin condition, the facility failed to ensure weekly skin audits were completed, per the physician's order.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for 2 of 5 residents (Residents #20 and 42) reviewed for unnecessary medications, the facility failed to ensure orthostatic blood pressure monitoring was completed per the physician's order for a resident receiving an antipsychotic medication.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to the implement the facility's policies and procedure for investigating an allegation of mistreatment.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review and interviews for one resident (Resident #1) reviewed for abuse, the facility failed to the report an allegation of potential mistreatment to the state agency timely.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for one resident (Resident #52) reviewed for wandering, the facility failed to develop a comprehensive care plan to address the resident's wandering behavior.

Inspectors wroteBased on clinical record reviews, review of facility policy and interviews for 2 residents (Residents #16 and #17) reviewed for pressure wound for Resident #16, the facility failed to ensure consistent monitoring of the resident's pressure relief mattress and for Resident # 17, facility failed to ensure the dietician addressed the resident's new pressure area and.

Inspectors wroteBased on clinical record review and interviews for 1 of 6 sampled residents (Resident #50) reviewed for unnecessary psychotropic medication use, the facility failed to monitor the resident's targeted behavior specific to the anti-psychotic medication use and the facility failed to monitor orthostatic blood pressure in accordance with the physician's order.