Nursing home resident’s choking death wasn’t investigated by state regulators

The state of Iowa never investigated a nursing home resident’s death that has been attributed to worker misconduct.

Earlier this week, the Iowa Capital Dispatch reported that an administrative law judge ruled in October that an employee of Des Moines’ Trinity Center at Luther Park nursing home had contributed to the July choking death of a resident by ignoring his boss’ orders.

The Capital Dispatch asked the Iowa Department of Inspections and Appeals, which oversees nursing homes, why the death wasn’t mentioned in the published reports that resulted from inspections at the home in August and October.

DIA spokeswoman Stefanie Bond said late Tuesday that the death was not self-reported to DIA by Trinity Center as required by Iowa law. In addition, she said, the agency’s Health Facilities Division had not fielded any complaints about the death. She said DIA inspectors will now be looking into the matter.

DIA’s Health Facilities Division, which has the responsibility of inspecting care facilities, is separate from the department’s Administrative Hearings Division, which handled the worker-misconduct case that brought to light the resident’s death.

Resident choked on meal and died

State unemployment records indicate that Richard A. Kerr was working as a cook at Trinity Center in July when two new residents were admitted. Kerr, who lacked access to residents’ medical records, wasn’t trained or authorized to create meal menus for residents and was told not to do so for the two newly admitted residents.

Kerr allegedly created the menus anyway and in doing so he created a “meal ticket” for a resident that indicated the individual could have a regular, or unrestricted, diet. That resident’s medical orders limited their diet to soft, bite-sized pieces of food.

As a result of the alleged error, the resident was given pulled meat instead of ground meat. The resident choked on the meat, was taken to a hospital and died. Kerr was fired several days later.

According to the findings of the judge who presided over a DIA hearing on Kerr’s request for jobless benefits, Kerr committed on-the-job misconduct that contributed to the death.

In her ruling, Administrative Law Judge Carly Smith noted that Kerr had been “made aware that it was dangerous for him to enter the meal tickets when he was not properly trained because it could have a harmful impact on residents, i.e. choking.” She wrote that “as a result of (Kerr’s) failure to follow directions, a resident choked on the food, was hospitalized and died.”

According to Smith’s ruling, Trinity Center had previously warned Kerr about creating resident menus. In February 2022, he had changed the menus for some of the residents, which resulted in his boss changing them back so they would conform to physicians’ orders.

After that incident, Kerr’s supervisor allegedly reminded him that he lacked the training and authority to specify food items for residents and she allegedly warned him of the potentially fatal risks associated with doing so.

Records related to death are sought

Earlier this week, the Capital Dispatch asked DIA for access to the six exhibits in Kerr’s unemployment case. Bond said that although DIA handled the case, the request for documents should be directed to Iowa Workforce Development, where such records are maintained.

An Iowa Workforce Development lawyer, Rebecca Stonawski, responded to the request by saying the Capital Dispatch would have to submit a signed “waiver” from either Kerr or Trinity Center, authorizing the release of the documents.

The Capital Dispatch objected and noted that the exhibits are a public record when an unemployment case advances to the level of an administrative hearing before a judge.

Stonawski then said IWD would be “happy to search for the documents,” and estimated the cost of locating them at $20 to $50. She added that IWD “team members are out this week” and the agency would get back to the news organization once the records were located.

The Capital Dispatch then asked for a breakdown of IWD’s expenses in locating the records, noting that in the past news reporters have been able to find specific case exhibits in less than 60 seconds by using a designated public-access terminal.

Stonawski has yet to respond.