State investigates 15 complaints against Sioux City nursing home, proposes fines

After fielding 15 complaints against a Sioux City nursing home, state inspectors have proposed a $30,000 state fine against the facility’s owners.

In late August, inspectors working for the Iowa Department of Inspections and Appeals went to the Westwood Specialty Care nursing home in Sioux City to investigate a backlog of 15 separate complaints and four self-reported incidents.

As a result of that investigation, the inspectors reported that at least 11 of the 15 complaints were considered substantiated. All four of the self-reported incidents were deemed substantiated.

The home was cited for failure to report alleged regulatory violations, inadequate timing and revision of residents’ care plans, failure to provide assistance with daily living, failure to provide adequate quality of care, failure to keep the home free of accident hazards, failure to employ sufficient nursing staff, failure to maintain a medication error rate of 5% or less, failure to follow physician-prescribed diets, failure to properly maintain a quality assurance committee, and failure to follow infection prevention and control guidelines.

The potential $30,000 state fine is being held in suspension while the Centers for Medicare and Medicaid Services considers the imposition of a federal fine in lieu of a state penalty. Over the past two and half years, CMS has fined Westwood Specialty Care more than $130,000.

The home, which is run by Care Initiatives of West Des Moines, has a one-star overall rating from CMS, which signifies the home is considered “much below average.”

According to inspectors, a female resident of the home who was considered to be in need of extensive assistance in transferring to and from her bed and chairs, was reclassified by the home as “independent” without any assessment to justify the change in status. Two weeks after she was labeled “independent,” the woman fell and sustained multiple upper- and lower-body fractures.

After the accident, the woman was not evaluated by a physician or an advanced registered nurse practitioner for four days, inspectors reported. She was eventually taken to a hospital and admitted with multiple rib fractures, a broken collar bone, a fractured pelvis, and a fractured wrist.

Another female resident of the home complained to inspectors that a non-certified aide had touched her breast and inserted a finger in her vagina and reportedly told inspectors she had reported the incident to the home’s occupational therapist. The therapist told inspectors she relayed the information to the director of nursing and the administrator. The director of nursing denied that and said if the matter had been reported to her, she would have informed the state as required.

Another resident of the home complained to inspectors that she had soiled herself after waiting 40 minutes for a worker to answer her call light. A licensed practical nurse allegedly told inspectors, “There is not enough staff, especially when we just have two nurses or are short on aides. It’s hard to answer call lights and do everything we have to do as nurses.”

One resident reportedly told inspectors, “They have no staff on the weekends here. We sometimes have one nurse on duty, sometimes two, but that is not enough. Call lights don’t get answered. Call lights take over one and a half hours on the weekends. Last weekend they took over an hour to answer my call light. I wet my pants, there was so much urine that it went through my briefs, my clothes, and through my wheelchair. It was dripping on the floor. It was so embarrassing and completely unnecessary.”

A male resident reportedly told inspectors that a nurse had complained he took too long to get ready for bed, adding that the nurse had then timed him at 18 minutes. The man allegedly told inspectors that he thought that he did “a pretty good job” considering his condition, and he noted that once in bed he often had to wait a long time for his call light to be answered. “When I am in bed, I am at the mercy of the call light,” he reportedly told inspectors.

With regard to residents not receiving their scheduled baths or showers, a nurse aide told inspectors that the staff did not always have enough time to provide that service.

Candace Gibson, the home’s administrator, could not be reached for comment Monday. When the home was cited for similar violations in February, it provided the state with a written response indicating it would “continue to provide a clean and safe environment” for residents and would “continue” to answer call lights in a timely fashion.