Eleven months after woman is found dead in a ‘puddle of blood,’ care facility is fined

By: - May 31, 2022 1:49 pm

The Exira Care Center was cited by state inspectors for having failed to report a resident's head injury to the Department of Inspections and Appeals. (Photo illustration by Iowa Capital Dispatch)

An Iowa nursing home where a resident was found dead in a pool of blood last summer after a series of falls has been fined $18,000 by the state.

Reports from the Iowa Department of Inspections and Appeals indicate that on June 11, 2021, a worker at the Exira Care Center in Audubon County found a female resident of the home lying face down on the floor of her room, dead and “in a puddle of blood.”  The woman had lacerations to right eye and her upper lip. A funeral home was called to pick up the body.

During the preceding two months, the woman had fallen several times at the home, inspectors alleged. On April 7, she fell and sustained a broken arm. Days later, on April 12, she was found on the floor with “a large amount of blood under her head,” inspectors reported, after she fell and injured her head and hip.

The Exira Care Center was cited by state inspectors for having failed to report the April 12 head injury to the Department of Inspections and Appeals as required. According to the inspectors, the home said it felt no report was necessary since a brain bleed that was spotted during the woman’s hospitalization had actually stemmed from the April 7 fall at the facility.

The home’s director nursing allegedly told inspectors that due to a staffing crisis during the COVID-19 pandemic, the facility had difficulty hiring workers and did not have enough staff on hand to provide residents with prescribed restorative care and services.

The home was cited for 11 federal violations, including deficiencies related to comprehensive care plans, overall quality of care, pressure sores, resident records, immunizations, the reporting of alleged violations and the accuracy of resident assessments.

The state fined the home a total of $18,000 for violations related to environmental hazards, medication and treatment.

The inspection was triggered by four complaints, three of which were substantiated, and three self-reported incidents at the home. The administrator of the home, Steve Fister, was not available for comment Tuesday.

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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.

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