Nursing home cited for ignoring woman’s injury and ‘unbearable pain’

A western Iowa nursing home already considered one of the nation’s worst could soon be facing additional penalties.

According to state records, inspectors visited Pottawattamie County’s Oakland Manor in May, in response to several complaints. While there, inspectors cited the home for violations of 17 federal regulations.

The inspectors alleged the nursing staff had failed to notify doctors of a female resident’s worsening condition, which resulted in a delayed hospital admission and “prolonged pain.”

The woman was ultimately admitted to a hospital, where she was diagnosed with acute kidney injury and acute diverticulitis. She needed an immediate transfusion of two units of blood due to an internal, gastrointestinal bleed that had not been addressed.

State inspector determined the woman had been continually passing out, had reported feeling dizzy and nauseous, had complained of “unbearable pain,” and had asked to be taken to a hospital. A nurse aide asked two licensed practical nurses to check the woman, but the LPNs allegedly failed to address the resident’s complaints or take the aide’s concerns seriously.

Once the day-shift nurse arrived, the nurse aide approached her, visibly shaking, asking her to “come right away” and check on the woman, inspectors reported. At that point, the woman was clammy, sweaty, in extreme pain and “begging to be sent to the hospital,” according to inspectors. The day-shift nurse transferred the resident to the hospital and the two LPNs were later fired, according to the inspectors’ report.

The home was also cited by inspectors for failing to ensure a registered nurse was on duty for at least eight consecutive hours per day, seven days a week. According to the inspectors, Oakland Manor failed to meet that legal requirement on seven of the 31 days on which staffing records were reviewed. The home’s administrator reportedly explained to inspectors that the company had been having some difficulty finding a nurse to work weekends.

The home was also cited for violating regulations that require nursing homes to post, in an area accessible to the public, their nurse-staffing data. Inspectors said that based on observations and interviews, Oakland Manor was not posting its nurse-staffing data for the public to see.

Other violations cited as a result of the May visit were tied to standards related to quality of care, medication and treatment, abuse-and-neglect training, the accuracy of residents’ assessments, respiratory care, nutritional issues, sanitary food-preparation services and quality improvement efforts.

No fines reported yet

As a result of the inspectors’ findings, the Iowa Department of Inspections and Appeals imposed a $9,000 fine that was tripled to $27,000 due to the repeated nature of the violations. However, that state fine was held in suspension by the department. No federal fines have been reported yet.

Oakland Manor currently has an overall rating of one star, on a five-star scale, from the federal Centers for Medicare and Medicaid Services. It also is eligible for inclusion on CMS’ list of special-focus facilities, which is a national list of some of the worst care facilities in the country.

Last December, CMS began withholding Medicare funding to the home due to quality-of-care issues. The funding restrictions lasted for 73 days.

That same month, CMS fined Oakland Manor $416,475 for regulatory violations. That fine, which was later cut by 35% to $270,708 because the home didn’t appeal it, has yet to be paid, according to state records.

Two months earlier, the home paid $82,798 in federal fines stemming from violations uncovered during a November 2020 inspection.

The home is managed by Administrator Erin Dye, and is owned by Oakland Healthcare and Oakland Realty Partners of Chesterfield, Mo. Dye could not be reached for comment Thursday.

In 2020, Oakland Manor was one of the first Iowa nursing homes to contend with a major COVID-19 outbreak, resulting in at least 51 infections and seven resident deaths.

According to an inspectors’ report, the Oakland Manor staff sent a fax to a physician on Aug. 3, 2020, to inform him of a COVID-19 patient’s deteriorating condition. Within three hours, the physician sent a response instructing the home to send the man to the emergency room of a local hospital. No one at Oakland Manor saw the fax, and 11 hours later, the staff at the home found the man dead in his bed.

Inspectors said it wasn’t until Aug. 17, which was 14 days after the man died, that a nurse in the facility noticed the physician’s fax ordering the resident to the emergency room.

Pottawattamie County Public Health officials had asked DIA to investigate the home earlier that summer, citing a spate of resident deaths there related to COVID-19. DIA’s inspectors had visited Oakland Manor several weeks earlier and reported it was entirely in compliance with federal COVID-19 prevention guidelines.