The nurse who state investigators say went to work at the Three Rivers nursing home in Norwich, Conn., knowing she may have been exposed to coronavirus – and then worked without a mask – could face a potential criminal probe as a part of an investigation by the state’s chief advocate for nursing home patients.
The state’s long-term care ombudsman said Tuesday that her office will seek licensure action and possibly criminal action in the case. Three residents have died amid an outbreak at the facility that state investigators linked to extensive shortcomings in care.
“We are looking at all of our options to hold individuals responsible for their action,” Long-term care ombudsman Mairead Painter said. “I do feel that this clearly rises to the level of an elderly abuse issue.
“Someone knowingly going into a facility, not feeling well and then going maskless is reckless behavior that endangered the lives of residents and led to this tragic situation.”
State officials, in their investigation of the outbreak, said the supervising nurse who came to work on July 24 knowing that two members of her family were awaiting COVID test results and not feeling well herself. The report did not identify the nurse.
DPH issued a “statement of deficiency” on Monday, citing the nursing home for a range of infection control deficiencies, including failure to properly use PPE and failure to properly quarantine an exposed resident. There was insufficient staff at times, the report said, to designate staffers to work exclusively with patients who tested positive for COVID.
The state is continuing its investigation and more actions could be taken against the owners of the facility – JACC Healthcare of Norwich Inc., which is based in Thomaston. The company, which has not responded publicly to the state’s report, also own homes in Windham and Danielson.
There are currently 57 residents in Three Rivers. Many of them have contacted Painter’s office seeking help with getting their loved ones moved to another facility, but that will be difficult for at least a few more weeks.
“All the residents at that facility are considered at-risk patients so no one will take them right now,” Painter said. “There choices are very limited right now and they can’t visit their loved ones. They are stuck. It’s just a tragic situation that could have been avoided.”
Painter said that her office is considering an ombudsman complaint against the nursing home facility for the way it handled the outbreak.
“The directives were pretty clear for cohorting and they just didn’t follow the appropriate procedures. It’s not like they didn’t have access to information and procedures. They just didn’t do what they were supposed to do,” Painter said.
Painter said she plans to call a meeting of the Coalition of Elder Justice to determine what actions should be taken against the individual supervising nurse and the facility and “we will look at it from all angles,” including licenses, administrative action and a possible criminal complaint.
DPH interviewed several staff who said that the supervising nurse – referred to in the report as RN#2 – came to work on July 24 and told co-workers that she wasn’t feeling well, was having a “sinus issue” and that two of her family members were awaiting COVID test results. Despite that several employees said they saw her working without a mask on.
She was working a double shift on July 24 that started at 3 p.m and didn’t end until 7 a.m. the next morning. Before starting her shift on July 24 the Director of Nursing Services (DNS) told investigators the nurse visited with her mother, who is a resident at Three Rivers, the report said.
“The DNS identified that RN #2 was the resident representative of Resident #22 and had visited with him/her prior to working 7/24/20,” the DPH report said. “The DNS stated that when s/he supervised the visit it was necessary to repeatedly ask RN #2 to replace his/her mask and step back to maintain the required social distancing from Resident #22.”
DPH investigators did interview the nurse, who told them she was tested during a routine staff screening on July 24 and got the positive test three days later. She told investigators “that two family members were tested and confirmed positive for COVID-19u2033 on July 26 and that “she had been exposed to both family members and she knew there was a possibility that she would test positive.”
She said she had been with several family members the previous weekend, two of which were the family members who eventually tested positive.
The DPH report said that the nurse who worked the overnight shift with her also has tested positive for COVID-19. The nurse, referred to as LPN#1 in the report, was interviewed by DPH investigators on Aug. 19.
“LPN #1 indicated that she had tested positive for COVID-19. LPN #1 stated that when she reported to work on 7/24/20 for the 11 PM to 7 AM shift, RN #2 indicated that she was not feeling well,” the nurse told investigators.
“During the shift on 7/24/20 LPN #1 further stated RN #2 had indicated that family members visiting from another state were awaiting pending COVID-19 test results. When RN #2 indicated she was experiencing “sinus issues”, LPN #1 asked her to move away,” the nurse said in the DPH interview.
All told, 22 residents and five employees have tested positive since the outbreak was discovered in early August.
The first resident to test positive was on Aug. 2, five days after nursing home officials knew that an employee had COVID. The resident had been transferred to Backus Hospital, where a COVID test was done.
Despite knowing at that point there were COVID patients in the facility the staff didn’t cohort anyone and several nurses and certified nursing assistants worked with both COVID positive and negative patients on the same shift, the report said.
The director of nursing services told DPH officials when they started their investigation on Aug. 17 that they didn’t have enough beds in any one unit to house COVID-only patients or enough staff to care for them despite pleas to the corporate office for more help.
The day after the DPH first entered the facility two residents who had not been sick developed symptoms and one of them was serious enough to be taken to the emergency room and was hospitalized. It’s unclear what the status of that patient is now.
