‘No idea what I was doing:’ Altoona home added to federal list of worst nursing homes

An Iowa nursing home where workers weren’t trained in CPR and where a nurse allegedly refused to perform CPR on a resident who later died has been added to the list of the nation’s worst nursing homes.

The Altoona Nursing & Rehabilitation Center was cited for 12 regulatory violations in June and was found to have placed all 95 residents of the home in immediate jeopardy.

The Altoona home is one of 10 Iowa care facilities eligible for inclusion on CMS’ Special-Focus Facility List, which is a national list of homes with some of the worst records of regulatory compliance.

The Altoona home was only recently added to the list of homes considered eligible for inclusion on the list based on poor performance.

After a state inspection in June, DIA officials reported that in the early hours of June 14, a worker at the home heard a female resident call out, “I think I am having a heart attack.” The worker went into the resident’s room and found the woman having a seizure and then becoming unresponsive.

A registered nurse initiated chest compressions and CPR, but with the resident still in bed rather than on a hard surface as recommended. The nurse reportedly performed CPR for a few minutes, grew tired and asked a licensed practical nurse who was in the room to take over.

Inspectors later reported that the LPN responded to the request by saying “she was tired, didn’t feel well and didn’t want to do CPR,” and that she also whispered to one of her colleagues that she was “too scared” to perform CPR.

A third worker then attempted chest compressions and CPR. That worker later told inspectors she had sat through a CPR class in high school five years before but had never performed CPR and “had no idea what I was doing.”

Several workers later told inspectors they didn’t use a defibrillator on the resident and were unsure whether the home even had one. One worker indicated she had last been certified in CPR 13 years ago.

The registered nurse allegedly told inspectors she had received no training at the home on what to do in a medical emergency, wasn’t certified in CPR and didn’t know whether the home had a defibrillator.

The resident was taken by ambulance to a hospital where she was pronounced dead.

In addition to being cited for failing to adequately respond to the woman’s needs, the Altoona home was cited for failing to complete criminal background checks on half of the eight workers whose files were examined and for several other regulatory violations.

DIA determined residents of the home were in immediate jeopardy, but within 24 hours the state agency claimed the situation had been corrected and the home had educated its staff on CPR, medical charting, acute changes in conditions, physician notification, defibrillators and other issues, and so the severity of the violation was lowered.

The state agency considered imposing fines totaling $9,750 but opted instead for a $500 state fine tied to the criminal background checks.

Eight months ago, DIA considered, but did not impose, a $17,750 state fine against the home, in part for failing to provide adequate treatment for a resident who, as a result, had to be hospitalized for a bone infection.

According to CMS’ consumer website, CareCompare, the last time the Altoona home faced any federal fines was in 2019. However, DIA’s consumer website indicates the federal agency fined the home $145,945 as a result of the January inspection, and that no federal fine was imposed as a result of the CPR-related violations found during the June inspection.

Among the nine other Iowa facilities considered eligible for special-focus status are these:

Aspire of Primghar – This home has been eligible for special-focus status for one month. In May, the state cited the home for placing residents in immediate jeopardy by failing to provide adequate assessment and interventions for four of the five residents whose care was reviewed. One resident missed many medical appointments because rides hadn’t been arranged; a resident who was scheduled to have surgery to remove kidney stones missed his surgery appointment; and a third resident wasn’t monitored for fluid overload after a change in medication, then went into respiratory distress and died. During their inspection, the DIA officials declared residents of the home to be in immediate jeopardy but within hours the agency had determined the situation had been corrected through staff education and policy changes, so the severity of the violation was lowered. DIA considered, but did not impose, state fines of $17,500. The most recent federal fine imposed against the home was in June 2020, according to CMS.

Cedar Falls Health Care Center – This home has been eligible for special-focus status for 27 months. In May, inspectors cited the home for failing to protect residents against burns by placing residents’ beds, some of which were low to the floor, alongside baseboard heaters. In April, a resident rolled out of bed and was found by workers laying directly on top of a heating element. The resident sustained burns covering up to one-fifth of his body, with up to half of those classified as third-degree burns. The worst of the burns resulted in white, charred flesh, with some of the resident’s skin cooked onto the heater itself. The burns “may have also damaged the underlying bones, muscles, and tendons,” inspectors reported. A nurse aide told inspectors that “for years” she had told people at the home the beds needed to be moved away from the heaters, noting that blankets and linens would occasionally fall onto the heaters and workers would “walk in and ask what the smell was.” A check of the heaters throughout the facility indicated the surfaces registered as hot as 214 degrees. During the inspection, DIA officials notified the home that residents were in immediate jeopardy, but according to agency records they had by then already declared the situation to be resolved through corrective action taken by the facility. As a result, the severity of the violation was lowered. The agency considered, but did not impose, state fines of $7,250. The most recent federal fine imposed against the home was in June 2019, according to CMS.

Rock Rapids Health Centre – This home has been eligible for special-focus status for four months. In January, state inspectors cited the home for failing to provide adequate assessments and intervention for six of seven residents whose cases were reviewed. One resident with COVID-19 lacked adequate assessments for breathing difficulty and low oxygen levels and was sent to an emergency room in severe acute distress while extremely dehydrated. Another resident whose blood sugar wasn’t checked was sent to the hospital for treatment of hypoglycemia. A third resident, who had tested positive for COVID-19, had pneumonia and sepsis, and was hospitalized for acute kidney injury likely caused by severe dehydration. The home was found to have placed residents in immediate jeopardy. DIA considered, but did not impose, fines totaling $27,750. The most recent federal fine imposed against the home was in June 2020, according to CMS. DIA’s website indicates CMS fined the  home $280,955 as a result of the January inspection.

The other Iowa homes deemed eligible for special-focus status are: Aspire of Muscatine; The Fleur Heights Center for Wellness and Rehab in Des Moines; The Ivy in Davenport; Oakland Manor; QHC Fort Dodge Villa; and QHC Mitchellville.

The Special-Focus Facility List is updated quarterly by CMS and includes homes deemed by CMS to have “a history of serious quality issues.” Those homes are enrolled in a special program intended to stimulate improvements in their quality of care through increased oversight.

While 10 Iowa homes are deemed eligible for that sort of assistance, they are not actually enrolled in the program or receiving the assistance.

That’s because the number of facilities on the list remains relatively constant, so new facilities can’t be named a special-focus facility, regardless of how poor their care is, until other homes in that same state improve and “graduate” from the list – a process that can take four years or more..

Nationally, there are normally about 88 nursing facilities on the list, with one or two slots to be filled by each state. DIA nominates the Iowa facilities for inclusion on the list, and CMS selects two from the state to be enrolled in the program.

Typically, homes that are eligible for special-focus designation have about twice the average number of violations cited by state inspectors; they have more serious problems than most other nursing homes, including harm or injury to residents; and they have established a pattern of serious problems that has persisted over a long period of time.