Resident bleeds to death at care facility that has a history of violations

An Iowa nursing home where a woman bled to death two weeks after moving into the facility is facing possible fines from the federal government.

The Iowa Department of Inspections and Appeals has cited Mount Pleasant’s Arbor Court care facility with failing to respond to an internal, electronic warning that pertained to two drugs administered to one of the home’s 59 residents last month.

The female resident was admitted to the home on Nov. 30, 2022. A week later, on Dec. 5, the facility’s electronic system of checking residents’ health records issued a warning pertaining to the resident, indicating a possible adverse drug interaction between her blood thinning medication and an antibiotic that she was receiving. The system noted the two drugs, when combined, had the potential to increase the risk of internal bleeding.

According to state inspectors, the woman’s patient records indicate the nursing staff at Arbor Court didn’t acknowledge the warning and didn’t notify the woman’s primary care physician, who had ordered the two drugs.

On Dec. 11, six days after the system issued the warning, a worker at Arbor Court turned the woman on her side and discovered a “large amount of foul-smelling, red and black substance” that appeared to be blood draining from a bed sore. The resident also showed signs of purple bruising, or pooled blood, in her feet, upper back and along her ribs.

The next day, on Dec. 12, the resident was admitted to a hospital emergency room and was found to have a gastrointestinal bleed. She had reportedly lost about four pints of blood – an amount equal to 45% of the blood an average-size woman typically carries in her body.

A test that is used to assess an individual’s risk of bleeding, which would normally indicate a so-called “INR level” of 2.0 to 3.0, showed the woman’s levels were literally off the charts – exceeding the 17.3 maximum level the laboratory device was able to measure. The hospital was in the process of giving the woman additional blood when she died, according to state reports.

The woman’s primary care provider told inspectors he had successfully prescribed the two drugs for the woman many times and that he didn’t feel a drug interaction had caused her death, according to state inspectors.

Three days after the death, a state inspector interviewed staffers at Arbor Court and was allegedly told there was a “medication book” that might have information relevant to the woman’s death. No one on the staff could find the medication book, and although a corporate clinical nurse consultant said the relevant information could be found in an electronic health record, “he was unable to locate it or show staff where to find it,” inspectors reported.

The home’s director of nursing allegedly told inspectors the facility maintained one desktop computer at the nurses’ station that had full access to the internet, and the staff could either use that computer or their personal cell phones “to Google medications” if they had any questions or concerns about medication dosages or drug interactions.

As a result of the inspectors’ findings, the state cited Arbor Court for one violation: failing to ensure that each resident’s drug regimen was free from unnecessary drugs. It was the second time in eight weeks the home was cited for that same violation. A $17,500 state fine was proposed, but it is being held in suspension while the federal Centers for Medicare and Medicaid Services determines what federal fines, if any, should be imposed.

Home has a history of violations

Arbor Court has the lowest rating possible – one star on a five-star scale – from CMS for its health inspections, staffing levels and overall quality. Over the past 14 months, it has been cited for several serious health-and-safety violations:

Bed sores: In November 2021, the federal government fined Arbor Court $166,551 after state inspectors cited the facility for failing to properly diagnose and treat residents’ bed sores.

Death: In January 2022, the state issued a suspended fine of $27,000 against Arbor Court after a resident of the home, Donna Lee Huffaker, fell to her death from a mechanical device that was being used to transfer her in and out of bed. CMS’ website indicates no federal fine was imposed against Arbor Court as a result of that incident.

Exposed bone: In February 2022, the state issued a suspended fine of $27,000 against Arbor Court for failing to identify, diagnose and treat a severe bed sore that left a resident with exposed bone and an infection that required hospitalization. CMS’ website indicates no federal fine was imposed against Arbor Court as a result of that incident.

Drugs: In October 2022, two months before the recent death tied to the drug interaction, Arbor Court was cited for failing to ensure that each resident’s drug regimen was free from unnecessary drugs. In that case, the state issued a suspended fine of $8,250. CMS’ website indicates no federal fine was imposed against Arbor Court as a result of that incident.

Affiliated care facilities sued after patient deaths

Arbor Court is operated by Midwest Geriatric Management Healthcare, also known as MGM Healthcare, of St. Louis. The company provides management services to 24 care facilities nationwide, including seven nursing homes in Iowa.

In 2018, MGM and one of its Iowa facilities, Oakland Manor, was sued by the families of three former patients.

In one case, it was alleged that the home and other health care providers failed to treat the bed sores of 66-year-old Richard C. Schneider, who subsequently died. The case has been inactive since last year when claims against some of the defendants were dismissed due to a tardy court filing.

In the second Oakland Manor case, the family of former resident Dane Nelson sued the home, claiming that Nelson, who was to be fed only while being supervised, died after he was found unresponsive in bed with food lodged in his throat. That case was later dismissed with no indication as to whether a settlement was involved.

In the third Oakland Manor case, Violet Mantzaris sued MGM and the home, claiming that while a resident of the western Iowa home, she contracted sepsis and other infections; suffered an acute kidney injury; had severe malnutrition and dehydration; was left with multiple untreated bed sores; and suffered from a lack of treatment for a broken arm, which triggered a need for surgical intervention. Court records indicate the case was dismissed after the parties agreed to a settlement.

In July 2022, the estate of Donna Lee Huffaker, the woman who died after falling from a mechanical lift at Arbor Court, filed suit against the home and MGM, alleging the facility had failed to call a doctor or summon an ambulance until three hours after the fall, by which time Huffaker had sustained irreversible brain damage. MGM and Arbor Court have denied any wrongdoing and the case is still pending.

In August 2022, MGM and one of its Oklahoma care facilities was sued by the family of Laverne Somers, who allegedly died after a fall at one of the company’s Oklahoma care facilities. The lawsuit alleges the company, “in order to satisfy their desire to grow profits, created a dangerous condition that caused harm to residents.” The company has denied any wrongdoing, and the case is still pending in federal court.

MGM Heathcare did not respond to calls Tuesday seeking comment on the Arbor Court death. The home’s administrator, Kerri Menke, could not be reached.