Abuse and neglect continued in 2020 at Glenwood, even while feds investigated

Gov. Kim Reynolds seen here at a news conference Aug. 4, 2020, said "what happened at the Glenwood Resource Center was unconscionable and unacceptable." (Screenshot from Iowa PBS livestream)

A state-run home for the disabled that has been the focus of a yearlong federal investigation continues to be cited for poor medical care and resident abuse.

The Glenwood Resource Center is the subject of a newly released report from the U.S. Department of Justice that confirms residents of the home were subjected to unauthorized experiments prior to the 2019 firing of the home’s top administrator.

In response to the DOJ’s findings, the Iowa Department of Human Services, which runs the western Iowa home, said in a written statement Tuesday that “our highest priority is the care and well-being of those we serve.”

State records show that throughout 2020, even with federal investigators on the Glenwood campus, the home has been cited repeatedly for failing to meet residents’ needs and for resident abuse.

On Dec. 4, the Iowa Department of Inspections and Appeals cited the home for failing to provide residents with adequate nursing services. The offense was deemed serious enough that DIA said Glenwood had placed all of the residents of the home in immediate jeopardy. The inspectors reported that a resident with a history of ingesting foreign objects had suffered a heart attack. The resident vomited at least 15 times the evening of June 13 before being taken by ambulance to a hospital, where he died.

According to DIA reports, Glenwood workers told state inspectors they questioned the quality of care provided by the nurse on duty in the home. The nurse told inspectors if he had more schooling in heart attacks, he would have known the client who died had suffered one. The nurse also questioned his colleagues’ medical charting, saying it appeared that they were “coached” on what to document in residents’ medical records. The home was fined $4,500.

In June of this year, the home was fined $4,000 after inspectors said the home failed to adequately respond to a 64-year-old female resident’s worsening condition. The woman was eventually taken to a hospital and diagnosed with cancer that had already metastasized to the liver. The resident died at the hospital one week after admission.  The woman’s primary nurse at Glenwood told inspectors that when she notified the home’s physician about a concern with a resident, she sometimes never received a response.

In April of this year, the home was fined $1,500 for failing to immediately report allegations of resident abuse, and $500 for inadequate nursing services. Inspectors said one worker at the home told them he had heard two colleagues talking about how they wore rings on their fingers to hit residents over the head, adding that the two had bragged about hitting residents and throwing feces at them.

In January of this year, Glenwood was fined $500 for resident abuse, with inspectors noting that Glenwood employees overheard a conversation between one of their colleagues and a resident, with the resident objecting to comments from the employee and saying, “Have some respect, my father just died.” The worker allegedly responded, “I don’t give a s—, my father has been dead for 10 years, so up yours! I wish you wouldn’t have came back. After you’re done, you can pack your s— and leave.”

Reynolds: What happened was ‘unconscionable’

In a written statement about the DOJ’s latest findings, Gov. Kim Reynolds said Tuesday, “What happened at the Glenwood Resource Center was unconscionable and unacceptable.” She said she is “committed to bringing all the tools and state resources needed to address the challenges at the facility.”

The DOJ issued its findings Tuesday, confirming what DHS had acknowledged in late 2019 when it fired the director of the home, Jerry Rea, and later its medical director, Mohammad Rehman. The scandal also contributed to Reynolds’ decision in June 2019 to demand the resignation of DHS Director Jerry Foxhoven.

The DOJ reported that “there is reasonable cause to believe” the experiments violated residents’ constitutional rights and subjected them “to unreasonable harm.”

The DOJ has not announced what steps, if any, it will take to address the issue, but it has warned the state that it might sue if it concludes DHS has not done enough to correct the problems outlined in the report.

Glenwood is home to roughly 185 Iowans, most of whom have profound mental and physical disabilities and require extensive assistance with the activities of daily living.

In addition to the findings pertaining to the experiments, the DOJ faulted DHS for being “deliberately indifferent” to the inadequate medical care that allegedly contributed to an increase in resident deaths from 2017 to 2019.

Among the DOJ’s specific findings:

  • Although Rea was hired in 2017 to clean up Glenwood in the aftermath of a scandal involving allegations of widespread abuse, the situation “became even more dysfunctional” with Rea at the helm, the DOJ found. “The quality of care declined as Glenwood leadership, managers, supervisors, and staff had to choose between, as a staff person told us, watching their backs and watching their clients. This decline in care was facilitated by a DHS central office that was unwilling, unable, or both, to recognize and address the problem.”
  • While preparing for sexual-arousal experiments involving residents, Rea “acquired a set of computer-generated images of nude and clothed children” that were stored on a computer at Glenwood.
  • Glenwood staff ordered workers to falsify records which were being maintained in a manner allowed for easy manipulation. In August 2019, a supervisor instructed a worker to rewrite the narrative of an report that described a resident attacking a staff member. The rewritten version stated only that the resident exhibited “dangerous behavior.” The change was ordered shortly after Glenwood was fined by the Iowa Occupational Safety and Health Administration for failing to protect staff from residents. Separately, a nurse who assessed a resident who claimed she had been sexually abused was ordered by a supervisor to change the records so the allegation would be falsely identified as one of physical abuse rather than sexual abuse.
  • At Rea’s direction, the DOJ says, Glenwood began experimenting on residents without their consent and without adequate oversight. One of those experiments resulted in residents who had been diagnosed with pneumonia being given increasing amounts of fluids “until there was a sign of a negative impact,” the DOJ reported. That form of “treatment,” the DOJ found, can cause dangerous complications and cause problems with the liver, kidneys, and nervous system. Some of the residents, including one who died, showed increased signs of pneumonia during the experiments.
  • The Glenwood staff failed to provide timely care for a resident who complained of stomach pain and asked to be taken to the hospital. The man died of a bowel obstruction that eventually ruptured. “Glenwood’s unresponsiveness to his initial complaint gave him virtually no chance of survival,” the report states.
  • After fielding media inquiries about the increase in deaths at Glenwood in 2019, DHS attributed the trend to residents’ age and took no steps to determine whether it was “linked to clinical deficiencies,” the DOJ found. DHS leaders also brushed aside complaints from Glenwood employees who complained about the quality of medical care in the facility and “made no attempt to investigate whether their concerns had merit.”

Feds have intervened at Glenwood before

This is not the first time the U.S. Department of Justice has investigated conditions at Glenwood. In November 2004, the DOJ and DHS entered into a court-approved settlement agreement that mandated improvements in care at the home.

At that time, the DOJ had concluded that Glenwood was providing substandard medical, psychiatric and psychological care; had used psychotropic medications without justification to control residents’ behavior; and had deficient or non-existent pharmacy oversight. The home was also accused of failing to obtain informed consent from residents or their guardians; and with providing inadequate nutrition management and physical therapy for residents.

The settlement agreement required that DHS change its practices at Glenwood and also required DHS to periodically issue reports on its progress in bringing the facility up to generally accepted professional standards of care.

The DOJ now says that while the 2004 agreement resulted in improvements at Glenwood, conditions in the home worsened once the agreement expired in 2010 and federal oversight was eliminated.

In 2017, six employees of the home were criminally charged with neglect and abuse of the Glenwood residents.  One of the workers was acquitted by a jury, two were found guilty by a jury, and three pleaded guilty.

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. His 2004 series on prosecutorial misconduct in Iowa was named a finalist for the Pulitzer Prize for Investigative Reporting. From October 2018 through November 2019, Kauffman was an assistant ombudsman for the Iowa Office of Ombudsman, an agency that investigates citizens’ complaints of wrongdoing within state and local government agencies.