VILLAGE GREEN OF WALLINGFORD REHAB & HEALTH CENTER
LOCATED: 55 KONDRACKI LANE, WALLINGFORD, CT 06492
VILLAGE GREEN OF WALLINGFORD REHAB & HEALTH CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS.
LEVEL OF HARM – IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on a review of clinical records, facility documentation, interviews and policies, the facility failed to provide the physicians ordered therapeutic diet for one of four (Resident #1) residents, who were reviewed for receiving a therapeutic diet. This resulted in actual harm for R #1 who choked and subsequently expired.
Continuing: Review of the CNA care card (plan of care that the resident requires) identified that the resident was an aspiration risk, required set-up and supervision for all oral intake and was prescribed a puree, extra moisture diet. A dysphagia pureed diet was described as foods that are thick and smooth and have a moist pudding-like consistency without pulp or small food particles according to the facility approved diet list. Record review and interview with LPN #1 on [DATE] at 11:14 AM stated that CNA #1 reported that Resident #1 and Resident #2 did not have dinner trays delivered to the unit on [DATE]. LPN #1 identified that she ordered dinner trays for the two residents’, delivered the meal tray to Resident #2 and upon entering Resident #1’s room, observed the resident to be unresponsive with a meal tray in front of him/her. LPN #1 stated R #1 had received R #2’s tray that consisted of a dysphagia advanced diet (chopped). LPN #1 stated she called for help and resuscitation was initiated at 6:21 PM, inclusive of CPR and suctioning. LPN #1 further stated that R #1 required supervision while in the dining room only as s/he had a history of [REDACTED]. Interview with LPN #3 on [DATE] at 12:20 PM stated she responded to R #1’s room for a code and observed and suctioned carrots including a baby carrot from the resident’s oral cavity prior to attempting rescue breathing (ambu bag). LPN #3 stated at that point LPN #2 attempted to aerate the patient, was unable and suctioned the patient again for more carrots. At that time EMS arrived and attempted the insertion of an endotracheal tube but was not successful. LPN #3 stated that the EMT utilized forceps to remove a carrot and a blob of food. Interview with LPN # 2 on [DATE] at 2:40 PM stated that upon entering the room he proceeded to the head of the bed to assist LPN #3 who was suctioning the resident. LPN #2 attempted to place an oral airway but met resistance, suctioned the resident for carrots and then placed the airway and attempted to aerate the resident. The resident was transferred to the hospital and subsequently expired. Interview with CNA #1 on [DATE] at 10:24 AM stated she informed LPN #1 that R #1 did not have a dinner tray then proceeded to assist other resident’s with their meals. NA #1 denied giving R #1 a dinner tray on [DATE]. NA #1 further identified that she was never provided orientation to the facility and/or policies and would often float to different units. Interview with the Administrator on [DATE] at 9:30 AM indicated that based on the facility investigation, NA #1 provided Resident #1 with another resident’s meal tray on [DATE] that was not pureed. The Administrator was unable to provide evidence that NA #1 was oriented to the facility.
Personal Note from NHAA Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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