A resident of Quinnipiac Valley Center nursing home in Wallingford had a fatal heart attack in February after the staff failed to give her all of her prescribed medications for several days, an investigation report shows.

The resident, identified by the state medical examiner’s office as a 41-year-old woman, was admitted to the Quinnipiac Valley Center on Jan. 28. She had a seizure disorder and “profound intellectual disabilities,” according to an investigation by the state Department of Public Health. Among the medications that they were supposed to be administered daily were Clobazam, Diazepam and Dilantin to help control the seizures.

Investigators learned that in the five days since the woman had been admitted, the staff had administered only one dose of the Diazepam, none of the Clobazam until the date of death and only one dose of Dilantin. The woman was found unresponsive in her bed on the evening of Feb. 2 and pronounced dead of a heart attack by a staff doctor.

The woman was one of three residents who died within a month, according to the office of the state medical examiner. On Jan. 16, a 70-year-old woman died of COVID at Yale New Haven Hospital, and on Jan. 24, a 64-year-old man died of complications from diabetes.

The deaths led to the DPH investigation that began Feb. 3, the day after the 41-year-old woman died. Earlier this week, the DPH issued an order to close the facility and move its 94 residents to other long-term care facilities. DPH officials have said they had no choice but to close the facility because of concerns for patients’ safety. 

The death was detailed in a 73-page inspection report, compiled by DPH inspectors after multiple visits to the facility and obtained by the Connecticut Mirror. 

Among the other findings: Another patient, diagnosed with diabetes, was rushed to the hospital because staff had failed to monitor their glucose level for several days as their blood/sugar level fell to dangerously low levels; staff treated recently admitted COVID patients without wearing the proper personal protection equipment because they were unaware the person had tested positive; and that staff treated patients who had COVID on the same shifts and on the same floor as patients who didn’t, violating protocols.

“My mind right now is very confused. I’m going through a panic stage right now,” Gregory Brooks, right, said Tuesday afternoon. He heard Monday afternoon about the closure announcement of the Quinnipiac Valley Center, where he has lived for eight years. Yehyun Kim / ctmirror.org

‘A bombshell’

“This whole thing that’s going on right now is a bombshell,” said Gregory Brooks, a resident at Quinnipiac Valley for eight years who has acted as a residents’ advocate, discussing complaints and issues with the staff and administrators.

“This is come out of the blue like a lightning bolt. I was not involved in any meeting. I was not involved in any sit-down discussions,” Brooks said. “How did this happen? Everybody in here is in the same boat as I am — shocked.”

Brooks said that there haven’t been major problems at the facility before and that he assumed that a facility run by Genesis, a national chain, would be a safe location.

“There’s four-star ratings, plaques all over the walls, and while there’s been issues with staffing, my guess they aren’t alone with that problem,” Brooks said. “Why should the residents have to pay for a mistake that the corporation made, you know?”

Brooks said he found out the facility was going to be closed from a staff member who came to check on him.

“Well, he goes, ‘I’m losing my job. And all the other staff are too, we’re all out of here. We’re all gone,’” Brooks said. “I hadn’t heard anything from anyone about anything. And to me, that’s like common courtesy that you would give people — even a landlord would take a few minutes to go up and tell you why he is evicting you.”

‘Immediate jeopardy’

Investigators with DPH’s Facilities Licensing and Investigations Section entered the building on Feb. 10 after receiving a complaint. It is unclear if the complaint was about the death of the resident a week earlier.

The initial inspection resulted in two findings of “Immediate Jeopardy,” meaning the violations were serious enough to risk imminent harm to life. Those two cases were the woman who died and the resident who needed to go to the hospital because their glucose levels were not monitored.

DPH investigators interviewed staff and administrators to determine how staff had failed to administer medication or conduct basic checks.

The DPH report states that administrators were “unable to explain why medications were not ordered and ensure they were received timely for administration to the resident, and why a resident receiving insulin was not monitored after a decrease in blood glucose levels was ordered. The interview failed to identify why admitting documentation was not reviewed by the attending physician for a resident receiving insulin, and why the facility was unable to prevent the significant medication errors.”

DPH directed a plan of correction, which included the appointment of a temporary manager on March 3. DPH appointed Kathrine Sachs as the temporary manager, the same person who was placed into the Three Rivers Health care facility in Norwich in 2020 when a COVID outbreak occurred in that faculty and four people died.

Three Rivers was the last long-term care facility closed down by the state. Sachs recommended that it be closed after only a few days overseeing that facility.

Sachs reported to DPH additional issues with the facility, including, among other things, systemic problems with medication errors, DPH officials said.

DPH identified five more instances of immediate jeopardy related to failure to administer medications appropriately and accurately to residents and failure to report adverse incidents.  

COVID patients

The facility also failed to put proper infection control precautions in place, the report states.  

The infection control issues revolved around two COVID patients who came to the facility in early February.

The inspection revealed that they weren’t identified as COVID patients to staff, so many of them went into their rooms not wearing proper PPE such as isolation gowns. Inspectors unknowingly visited the room of one of the COVID patients during one of their inspections.

Several staff members told DPH inspectors they had no idea one of the residents was COVID positive and that they had treated other patients after going into the rooms of the COVID-positive resident.

Following the inspections, DPH notified Quinnipiac Valley officials that they had until early March to present a plan of correction, but after Sachs took over as temporary manager, the decision was made to close the facility and find new homes for 94 people.

“We have given QVC ample time to correct the issues, and DPH staff have been monitoring the facility almost daily. We no longer have confidence that the facility can keep its residents safe. Moving people from their homes on short notice is a serious action that we do not take lightly. But we are convinced that this order is necessary to ensure the safety of all the residents there,” said Department of Public Health Commissioner Manisha Juthani.

Quinnipiac Valley is owned by the Genesis Corporation, a national chain. Genesis issued a statement earlier this week that it was cooperating with the temporary manager and helping to relocate residents.

Asked if the health department is investigating any other Genesis facilities, DPH spokesman Christopher Boyle said, “DPH is not able to confirm or discuss any types of impending investigations at other facilities.”

State Long-Term Care Ombudswoman Mairead Painter said her office has been working with families and Sachs, the temporary manager, to find new homes for residents, hopefully within proximity to Wallingford.

“We are supporting the residents in as much choice as possible, related to the transfer and where they would like to go to try to remain close to either family or care providers or to stay with a roommate,” Painter said. “This isn’t something that we really see happening often. And because of the level of concern, we are really prioritizing the safety and well-being of residents.”

For Brooks, the ordeal of waiting to see what’s next has become excruciating. 

“I gave them my three choices, and they were all shut down,” Brooks said. “They don’t have any beds, which I can understand, since it’s 94 people getting thrown out.”

Dave does in-depth investigative reporting for CT Mirror. His work focuses on government accountability including financial oversight, abuse of power, corruption, safety monitoring, and compliance with law. Before joining CT Mirror Altimari spent 23 years at the Hartford Courant breaking some of the state’s biggest, most impactful investigative stories.