‘Something’s wrong:’ Inspectors watch as COVID-19 spreads in Iowa nursing home

By: - July 2, 2020 3:22 pm

(Photo by Centers for Disease Control and Prevention)

A third Iowa nursing home where residents have died of COVID-19 has been cited by the state for failing to observe basic health care protocols in the midst of the pandemic.

According to state records, the Mitchell Village Care Center has at times been staffed by only one low-level nurse aide to look after 40 or more residents; a man known to be infected with the virus wandered the home without a mask; a nurse complained the situation was “free-for-all, with no leadership from management”; and the director of nursing told inspectors the home was “falling apart” with “bed-ridden, weakened residents with no one to help them.”

There have been at least 22 infections reported at the Mitchellville home, with eight residents hospitalized and two deaths. The facility, also known as the QHC Mitchellville care facility, is home to roughly 45 older Iowans.

Last week, the Iowa Capital Dispatch reported 51 residents and staff at a Dubuque nursing home tested positive for COVID, and 11 residents died, after inspectors said three workers with symptoms of COVID-19 were allowed to work in the home. The three workers later tested positive for the virus.

This week, the Associated Press reported that 79 residents and staff members at an Oskaloosa nursing home tested positive for COVID-19, and 15 residents died. One worker at the home, who later tested positive for the virus, had been allowed to “self screen” before working shifts in the building, inspectors reported.

State records indicate that even the most basic infection-control protocols were ignored at the Mitchellville home when inspectors visited in early May, several weeks into the pandemic.

The Iowa Department of Inspections and Appeals alleges that on May 7, as the agency’s inspectors watched, one of the male residents who had tested positive just 10 days before wandered into a hallway and commons area of the home, huffing and puffing, saying, “Something’s wrong.”

The resident, inspectors said, was not wearing a face mask. An hour later, the same resident was seen again in the hallway, huffing and puffing, and short of breath. A few hours later, inspectors saw the man out of his room again, near the dining room, with labored breathing. According to state records, the man was touching the top of the nurses’ station, struggling for breath, yet the three staffers nearby, including the director of nursing, failed to intervene and redirect him to his room. They also didn’t sanitize the nurses’ station.

The next day, the same man was reportedly seen again in a hallway of the home, struggling for breath and leaning against a cart that stored clean linens to be used in other residents’ rooms. A staffer directed the man back to his room, but didn’t clean the cart that, according to inspectors, the man had “breathed on, directly, within less than a foot (arm’s length) for several minutes.”

Later that same evening, the man emerged from his room and stood near a row of clean face shields that were lined up for use by the staff. Inspectors said they watched as the man “huffed and puffed against the face shields … and he touched the face shields with his bare hands.” A worker asked the man to go back to his room but didn’t move or clean the face shields.

Another resident of the home told inspectors he was aware some of his fellow residents died after they tested positive for COVID-19, and said he felt the home was putting his life in danger.

That same day, inspectors watched as staffers made their rounds and failed to sanitize equipment or don the protective gowns intended to limit transmission of the virus.

Inspectors also reported overflowing trash bins and “clean” personal protective equipment, or PPE, being stored in a utility room alongside soiled equipment and biohazardous waste.

The director of nursing — who also served as the home’s infection control specialist — told inspectors she had been in the job for a month and that after 20 or so residents tested positive for the virus, she “tried to move residents” to minimize the spread, “but still had no idea what to do.”

She said the previous director of nursing was supposed to train her but “walked out” before doing so. She told the inspectors she did not know where the home’s infection-control program policies were located and she could not say what the specifics of the program were.

According to the inspectors, the director of nursing also said the staff had not received training and the home was “falling apart.” She spoke of “bed-ridden, weakened residents with no one to help them.”

The inspectors reported the director of nursing informed the home’s administrator she “could no longer be considered” director of nursing as she could not perform all of the tasks assigned to her, had received no training to do the job, and “did not know the ins and outs of it.”

A nurse aide told inspectors she was not instructed by the home’s administrators what to do with PPE, where it was stored, how to get it, or how to disinfect it. She said she was given no training on the virus, and felt “everything in the facility is a mess.” A registered nurse described the situation for inspectors as a “free-for-all, with no leadership from management.”

Staffing was a major problem, with the director of nursing telling inspectors she called everyone she could, including the United Way, looking for help, and was relying on eight different temp agencies to find workers. She said one of her colleagues had called the local fire and rescue squad for help, but they were short-staffed, too.

The inspectors’ review of personnel records allegedly showed entire eight-hour shifts with only person on duty to care for 40 or more residents. One registered nurse reportedly worked 28 hours straight at the home.

An aide who was alleged to be the only staffer working in the building from 11 p.m. one evening until 1:30 the next morning, told inspectors she tried to answer residents’ call lights while also working the phones in an effort to find someone to come in and help. She couldn’t reach anyone in management, she told the inspectors.

The home is run by QHC Management, which owns and operates at least seven Iowa care facilities. The limited liability corporation is owned by Jerry and Nancy Voyna of West Des Moines. Since 2011, the Voynas have contributed $36,000 to the Iowa nursing home industry’s primary political action committee, which in turn provides money for the campaigns of statehouse and gubernatorial candidates.

Jerry Vonya could not be reached Thursday by the Iowa Capital Dispatch.

There have been 56 COVID-19 outbreaks in Iowa nursing homes, and 380 COVID-19 deaths in those facilities.

Gov. Kim Reynolds was asked about the problems at the Dubuque nursing homes last week and said, “it’s just something that shouldn’t happen … I do want to reiterate, though, in the context of this, that there are a lot of long-term care facilities that are doing a phenomenal job.”

On April 6, Reynolds commended the state’s nursing homes, saying she had met with industry lobbyists about the need to protect older Iowans  in care facilities. “I want Iowans to know that we knew that this would be an extremely vulnerable population,” Reynolds said at the time, “and that’s why we took very significant measures early on to start to really limit access to protect and to make sure that we were doing everything we can to mitigate the effect of COVID-19 on our vulnerable Iowans.”

On June 18, Reynolds signed legislation granting Iowa nursing homes and other care providers immunity from COVID-19 lawsuits. She has said the bill includes “appropriate exemptions that still permits some lawsuits for reckless or willful misconduct,” but the bill itself has exemptions only for acts “intended to cause harm,”  those that involve “actual malice,” and those that involve in-patient hospitalizations or deaths.

Even before the pandemic struck, the Mitchellville home was cited by state inspectors for serious violations. In January, the home was fined $23,000, with inspectors alleging 19 regulatory violations, including inadequate nursing services and failure to provide a safe environment. In 2019, the home was cited for 16 regulatory violations.

As a result of the May inspection, the Vonyas’ Mitchellville facility was fined $30,500 by the state — but only symbolically. In keeping with new federal guidelines, all of the state fines imposed against nursing homes during the pandemic are being held in suspension. The $23,000 in state fines stemming from the January inspection have also been suspended, allowing federal officials to impose a fine of their own.

A total of 21 Iowa care facilities have been cited for regulatory violations since the beginning of the pandemic, but their fines, totaling $108,250, have all been suspended.

The homes, and the fines, include:

  • Thomas Rest Haven, Coon Rapids: $8,750 and $500
  • Garden View Care Center, Shenandoah: $9,000
  • Glenwood Resource Center, Glenwood: $1,500, $500, $4,000
  • GHC Winterset North, Winterset: $4,000
  • Good Samaritan Society, Algona: $8,250
  • Neuro Restorative, Ankeny: $5,250
  • Neuro Restorative, Iowa City: $6,000
  • Behavioral Technologies, Des Moines: $9,500
  • Behavioral Technologies, Marion: $500
  • Carriage Hill, Dubuque: $6,750
  • Carlisle Center for Wellness & Rehab, Carlisle: $3,500
  • Village Northwest Unlimited, Sheldon: $500
  • Pearl Valley Nursing & Rehabilitation, Muscatine: $10,000
  • ManorCare Utica Ridge, Davenport: $8,500
  • Oakview Nursing & Rehabilitation, Burlington: $6,750
  • Good Samaritan Society, West Union: $8,500
  • QHC, Mitchellville: $10,000; $10,000; $10,000; $500
  • The Suites at Western Home, Cedar Rapids: $3,000
  • Dubuque Specialty Care, Dubuque: $10,000
  • Crystal Heights, Oskaloosa: $8,750
  • Friendship Haven, Fort Dodge: $7,500

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Clark Kauffman
Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing.