Connecticut State Department of Public Health

Press Releases

08/31/2020

DPH Finds COVID-19 Outbreak at Three Rivers Nursing Home in Norwich the Result of Serious Infection Control Violations

DPH Investigation Results in ‘Immediate Jeopardy’ Finding and Federal Enforcement Action Following Outbreak that has so far Infected 21 Residents and Five Staff 

The Connecticut Department of Public Health today announced the issuance of a statement of deficiency for the Three Rivers Nursing Home in Norwich following an investigation into an ongoing outbreak of COVID-19 that has so far infected 21 residents of the facility and five staff members.  Three of the residents to test positive have died and one is hospitalized.  The rest are recovering in the Three Rivers facility, segregated from other residents who have not tested positive.  DPH has been investigating the outbreak since August 17, 2020 including daily on-site visits, reviews of facility records, and interviews with multiple residents and staff at Three Rivers.  A statement of deficiency is a federal enforcement action made by DPH as the investigatory agent for the Centers for Medicare and Medicaid Services (CMS), the federal entity that regulates nursing home participation in the Medicare and Medicaid programs.  Findings of deficiency can be made after violations in management or practice are found in a nursing home that puts patient care at risk.  In this case, DPH has issued a finding of immediate jeopardy, meaning the violations are serious enough to risk imminent harm to life.  In addition to these findings of violation of federal standards, DPH is investigating whether state regulations, laws or executive orders were violated by the facility.

“DPH is deeply saddened by the further loss of life in nursing homes related to COVID-19.  We will continue our robust monitoring and enforcement activities in partnership with CMS to ensure that nursing homes are providing a safe environment for their residents” said Acting DPH Commissioner Deidre S. Gifford, MD MPH.  “Our investigation uncovered system-wide failures in this nursing home in infection control practices, that merited the finding of immediate jeopardy.  DPH is committed to holding facilities accountable and ensuring that improvements in patient care are made so residents’ lives are not put in danger.”

The DPH investigation revealed that the COVID-19 outbreak began on July 24, 2020 when a staff member tested positive through routine weekly testing. There were serious violations found facility-wide in general infection control practices, staffing, cohorting (grouping together) residents who tested positive, and use of personal protective equipment (PPE).  The detailed, full investigative report in the statement of deficiency is available online by searching for it by date (between August 25-30).

Key Findings of the investigation include:

  • The facility failed to ensure appropriate cohorting of residents to prevent the transmission of COVID-19

     

  • The facility failed to utilize Personal Protective Equipment (PPE) in accordance with Centers for Disease Prevention and Control (CDC) standards

     

  • The facility failed to ensure appropriate designation of staff

     

  • The facility failed to maintain an updated, accurate or accessible outbreak listing of the COVID-19 status of the residents.

     

  • The facility failed to ensure that a required 14-day quarantine was maintained for a resident exposed to COVID-19.

     

  • The facility also failed to ensure that an aerosolized medication was administered to that resident in a manner consistent with current infection control standards, putting that resident and staff at risk of exposure to COVID-19.

     

  • The facility also failed to ensure that visitor screening regarding a person's recent travel history was conducted in accordance with an Executive Order dated 6/25/20 that was issued by the Governor of the State of Connecticut.

     

  • Additionally, the facility failed to ensure appropriate storage of reusable isolation gowns to maintain infection control standards.

     

  • The failure of the facility to implement the necessary measures to prevent the transmission of infection was determined to constitute a finding of Immediate Jeopardy (Endangering of Human Life).

 By federal law, Three Rivers has 10 days to present a corrective plan of action to DPH to show how it will address the findings and improve patient care.  DPH is also expecting more enforcement actions against Three Rivers to follow.