Bridgeport Health Care Center

In the surveyor’s words

From the most serious findings on record at Bridgeport Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF609Mar 15, 2021

  Based on observation, medical record review, review of facility witness statements, review of the facility Abuse policy and procedure, review of a facility self-reported incident (SRI) report, and resident and staff interviews, the facility failed to ensure an allegation of sexual abuse was reported immediately, but no later than two hours after the allegation was made, to the Administrator and State agency as required. This resulted in Immediate Jeopardy on 03/03/21 between 8:00 P.M. and 9:00 P.M. when Resident #24 alleged to Certified Nursing Assistant (CNA) #200 and State tested Nursing Assistant (STNA) #201 that she had been sexually abused (touched in her vaginal area) by Resident #100. […]

• Actual harm, isolatedF686Feb 29, 2024

  Based on observation, medical record review, staff interview, and policy review, the facility failed to monitor Resident #36's skin under a splint/boot on the left foot to prevent the development of a pressure ulcer. Actual harm occurred on 12/26/23 when Resident #36, who was cognitively impaired was identified to have a deep tissue injury (DTI) pressure ulcer (described as intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the left foot caused by a splint. The splinting device had been implemented following a fracture on 12/18/23. However, staff failed to monitor/assess the resident's skin integrity under the splint resulting in the DTI pressure ulcer development. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on medical record review, staff interview, and policy review, the facility failed to ensure Resident #36 received adequate staff assistance during a staff assisted transfer from bed to chair to prevent a fall with injury. Actual harm occurred on 12/18/23 when Resident #36, who was cognitively impaired, at risk for falls and required substantial/maximal assistance from staff for transfers sustained a fall during a one-person staff assisted transfer. At the time of the transfer, the nursing assistant, (NA) #170 failed to use a gait belt and the resident fell to the floor with a resulting fracture of the left ankle. This affected one resident (#36) of four residents reviewed for falls. The facility census was 92. […]

• No harm, potential for more than minimal, widespreadF880Apr 11, 2022

  Based on observation, record review, facility policy and procedure review, review of the Centers for Disease Control (CDC) guidance and interview the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE) and isolation precautions to prevent the potential spread of COVID-19. This affected two residents (#49 and #185) and had the potential to affect all 84 residents residing in the facility. Findings Include: 1. Review of Resident #49's medical record revealed an initial admitted [DATE] with the latest readmission of 04/01/22 with the admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF607Mar 15, 2021

  Based on observation, medical record review, review of facility witness statements, review of the facility Abuse policy and procedure, and resident and staff interviews, the facility failed to effectively and immediately implement the abuse policy regarding reporting and investigation of allegations of abuse. This affected one resident (Resident #24) whose allegation of sexual abuse was not reported to the Administrator or Director of Nursing. Therefore, an investigation was not started until six days after the alleged incident. This had the potential to affect all 88 residents residing in the facility who were at risk for potential harm or injury related to incidents of resident to resident sexual abuse. Findings include: Interview with the Administrator on 03/08/21 at 11:50 A.M. […]