Iowa care facilities cited for violations related to patient abuse, deaths

By: - December 1, 2021 3:26 pm

Since October 1, the Iowa Department of Inspections and Appeals has issued fines or citations against 22 of the state’s health care facilities, with fines totaling $53,787. (Photo by Getty Images)

State regulators have fined Iowa health care facilities more than $50,000 in recent months for violations related to physical and verbal abuse, inadequate care and patient deaths.

Since Oct. 1, the Iowa Department of Inspections and Appeals has issued fines or citations against 22 of the state’s health care facilities, with fines totaling $53,787.

One of the most serious cases involves the Casa de Paz nursing home in Sioux City. The home was fined $500 by DIA in October after being cited for failing to provide adequate care for a resident who died shortly after being rushed to a hospital.

Inspectors alleged Casa de Paz failed to complete a thorough physical assessment for a female resident who had been vomiting, complaining of constipation and asking to be examined by a physician or sent to the hospital.

One of the EMTs who eventually transported the resident to the hospital told inspectors that when the ambulance team arrived at Casa de Paz, they were stopped at the door and told they could not enter. The EMT said he looked through the door and saw the resident propelling herself forward in a wheelchair, pale and struggling to breathe. The EMT said the resident informed them she’d had no bowel movements in five days, had not urinated for three days, and had been vomiting for five days.

At the hospital, the resident was diagnosed with a bowel obstruction and died within 10 hours of admission.

A few weeks before the October inspection, the home was cited for 13 regulatory violations, including failure to have a properly certified dietary manager on staff for the past two years. In the kitchen, inspectors found moldy food and a “floor covered in a sticky residue and crushed food particles.” When asked for the written log of kitchen cleanings, the dietary manager said it was covered in mold, but he’d try to retrieve it. Later, he said it had “run off” and couldn’t be found.

While that violation didn’t result in any financial penalties, the facility was fined $500 for not completing criminal history and abuse background checks on all employees.

Other facilities cited for violations in the past two months include:

Good Samaritan Home, Ottumwa – In November, inspectors cited the home for failing to report an August allegation of physical abuse to local law enforcement and failing to thoroughly investigate the matter. Inspectors said the home’s director of nursing acknowledged that a nurse had reported an allegation of abuse that involved an employee striking a resident of the home in the head. No fine was imposed, and the home did not file a plan of correction with the state, stating that it was an issue of “past noncompliance.”

Northridge Village, Ames – The home was fined $10,000 in November for transferring a resident in or out of bed with only one staffer present and without a safety belt being used, in violation of the resident’s care plan. The resident fell to the floor, sustained a hip fracture and died during surgery to repair the fracture. The certificate of death lists the manner of death as an “accident” and states that it was due to “complications from a fracture of the right hip” caused by a fall.

Vita Health Services, Des Moines – This residential care facility was fined $500 in November for failing to report resident elopements to the state as required. A resident of the home had walked away from the facility on May 20 and July 8. Staff wasn’t aware of the May 20 elopement until contacted by police. The administrator told inspectors she was unaware of the state regulation requiring nursing homes to report elopements.

Good Samaritan Home, Davenport – The home was fined $5,750 in November for resident abuse related to the use chemical restraints and tranquilizers to control the behavior of residents. Two medication aides told inspectors they were directed by a registered nurse to give a male resident of the home Dilaudid, Hydroxyzine and Trazodone at the same time, despite the fact that the drugs are known to cause confusion, lethargy and other medical issues, especially when used in conjunction with each other.

The aides said the nurse who gave the order didn’t like the male resident’s behavior and had instructed them to “to give him everything he could have — give him a cocktail,” referring to a combined mixture of medications. According to inspectors, the nurse admitted she ordered the medications due to the resident’s behavior, which included trying to get up out of bed and throwing things.

The inspectors determined there were 17 missing Trazodone doses at the facility, and the nurse acknowledged they may have been given to the resident and not documented. Another nurse said she didn’t know where the missing drugs had gone but that she “wouldn’t be surprised” if the staff administered the drugs without documenting that fact.

A family member told inspectors he or she had told the staff numerous times not to give the resident drugs that added to his confusion and lethargy. On Sept. 28, the family member asked for an ambulance to take the resident to the hospital for an evaluation in light of his ongoing deterioration. The nurse who had ordered the drug cocktail allegedly said no one could take him out of the facility without a doctor’s order and then refused to provide a list of his medications. A hospital physician allegedly told inspectors the resident’s severe confusion, weakness and lethargy were due to the medications provided at the home.

Mosaic, Nevada – This intermediate care facility for people with intellectual disabilities was fined $500 in October for resident abuse. According to inspectors, one worker at the home had expressed frustration with a client of the facility due to the client’s pacing and called the client an “(expletive) moron.”

That same employee, along with another worker at the facility, were alleged to have a made up a song that mocked the resident. The two allegedly “showed” the song – either its lyrics or a recorded performance – to another worker who reported the incident three weeks later.

The two direct support professionals involved in that incident were also accused of observing a resident listening to music with his tongue hanging out, with one of the workers telling the man he should put his tongue in his mouth or she would cut it off.

A state review of the facility’s internal investigation confirmed the two workers had “mistreated multiple individuals in the home” by subjecting them to “verbal abuse and personal degradation.”

Several employees “reported numerous additional instances” when the two had mocked clients, swore at them and called them inappropriate names, which the staff had failed to report. The two accused workers had allegedly called clients “morons” and “crackheads” on a regular basis, and in one instance they responded to a client who was asking for a beverage by yelling at him, “Stop (expletive) talking, we’re talking,” as they conversed at a nearby dining room table. The two workers were fired after the internal investigation.

Mosaic, Belmond – This intermediate care facility for people with intellectual disabilities was fined $500 in October for resident abuse. An employee of the home reported that a direct support associate verbally degraded a client by telling the client he was “disgusting” because he had “s— himself.” A client of the home reported seeing that same direct support associate hit another client while calling him a Mexican.

In a separate matter, an employee of the home had filed a complaint against her supervisor for physical and verbal abuse. The employee alleged the supervisor heard a client arguing with staff and came out of her office and got in the client’s face, pushed the client with two hands to the chest and asked him how he liked it. In a separate incident, the same supervisor was alleged to have taunted and bullied a client by pushing him and asking him to hit her and see what happened.

Aspire of Muscatine – The home was fined $500 in October after being cited for 16 regulatory violations. The fine was for failing to treat residents with dignity and respect. One resident told inspectors an aide came to his room that morning and spilled from his catheter onto the floor by his bed, then refused to clean it up and instead put a blanket over the spill. Another worker came in later, stepped in the urine and when the resident asked if he would clean it up, she allegedly replied that it would depend on his attitude.

The man told inspectors the staff sometimes took 45 minutes to answer call light, which resulted in him defecating in bed. One aide acknowledged she had told residents who asked for assistance that they could care for themselves, which resulted, she said, in threats of complaints to the state inspections agency. The aide told inspectors she was attempting to “support independence” among the residents by denying them assistance.

Other employees of the home acknowledged 30- to 40-minute delays in answering call lights due to short staffing. A one-legged resident complained of waiting up to an hour for assistance to get to the bathroom. He told inspectors it “was bad enough to have to wait so long,” but it was “even more demeaning” to be forced to lie in his own waste until someone cleaned him up.

Parkridge Specialty Care, Pleasant Hill – The home was fined $325 in October after being cited for 17 regulatory violations. The inspection was triggered by 10 complaints to the state, and the fine was tied lengthy delays in answering residents’ call lights.

With inspectors in the facility on Sept. 1, residents were observed waiting up to 44 minutes for a response when they switched on their call lights. One resident was left waiting on the toilet for more than 30 minutes. During interviews with inspectors, residents reported waiting up to 90 minutes, saying they were “humiliated” by being forced to soil their bed. A review of the call-light system’s electronic record confirmed recent wait times for 60 to 90 minutes, and several wait times of three to five hours.

The home was also cited for medication errors; for failing to notify the family when a resident was taken to the emergency room, which meant the resident was alone in the ER for eight hours; failure to keep residents’ rooms clean and sanitary;  failure to follow physicians’ orders; failure to investigate signs of potential abuse; failure to provide baths for up to two weeks; failure to employ sufficient nursing staff; and failure to employ sufficient kitchen staff to feed residents. No fines were imposed for those violations.

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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. 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.