State agency violated the law by imposing a lesser fine for nursing home death

State regulators acknowledged this week that they failed to comply with a law requiring them to triple a fine against an Iowa nursing home where a woman bled to death.

Last month, the Iowa Department of Inspections and Appeals imposed, and then suspended, a state fine of $17,500 against Mount Pleasant’s Arbor Court care facility.

Initially, DIA did not post to its website the written citation that resulted in the fine. The Iowa Capital Dispatch requested a copy of the document and, after reviewing it, asked DIA why the fine against Arbor Court appeared not to have been tripled as the law requires when a nursing home repeatedly commits the same serious violations in a one-year timeframe.

The department acknowledged Wednesday it had failed to triple the fine as required. Spokeswoman Stefanie Bond said the staff mistakenly doubled an $8,750 fine to $17,500, when the fine should have been tripled to $26,250. DIA has since amended the citation to reflect the larger fine.

Under Iowa law, the director of the Department of Inspections and Appeals is required to triple the penalties against nursing homes for any second or subsequent Class I or Class II violations – which are the most serious type of violations – if they occur within 12 months of the previous violation.

In the Arbor Court case, a December death at the facility resulted in a citation for a Class I medication-and-treatment violation. That was just two months after DIA inspectors cited the home for the same type of Class I violation and imposed an $8,250 fine.

Other fines not tripled as law requires

The Arbor Court case is not the first time the state agency has failed to triple a fine against a repeat violator.

In 2020, the Iowa Capital Dispatch asked DIA about a $7,250 fine that had been imposed against the Rowley Memorial Masonic Home in Perry. DIA inspectors had cited the home for contributing to a resident death, hiring an unlicensed caregiver, failing to protect residents from sexual abuse and allowing a kitchen worker to supervise its dementia ward.

A $7,250 fine against the home should have been tripled to $21,750 because of previous, recent citations for the same violations. DIA blamed a “clerical oversight” for the lower fine, and it subsequently increased the penalty against Rowley to $21,750.

In both the Arbor Court and Rowley cases, the state fines were largely symbolic since both were held in suspension so the Centers for Medicare and Medicaid Services could determine what federal fines, if any, should instead be imposed.

In the Rowley case, CMS imposed a $181,785 fine, at which point Rowley pleaded financial hardship and the penalty was reduced to $100,435. The home was sold soon after and renamed Perry Lutheran Home.

In the Arbor Court case, the DIA and CMS websites indicate CMS has yet to impose a federal fine against the home for the December death – although the data on fines that is published by CMS and shared with DIA is often out of date or incorrect.

Last month, for example, DIA reported that CMS had levied a $909,600 fine against the Lenox Care Center in Taylor County. After the Iowa Capital Dispatch inquired as to the accuracy of that number, DIA acknowledged the actual fine was only $75,285, and attributed the error to inaccurate information it had received from CMS.

Earlier this year, DIA officials admitted the agency had not complied with a state law requiring the routine inspection of hotels every two years. After the Iowa Capital Dispatch asked DIA Director Larry Johnson why so few hotels appeared to have been inspected by the agency during the past seven years, he acknowledged the agency wasn’t performing the legally required biennial inspections and hadn’t been doing so since 2014.

Death linked to drug interaction

According to state inspectors, the December death at Arbor Court is tied to an interaction between an antibiotic and an anticoagulant medication that was administered to one of the home’s 59 residents just a few weeks after the woman was admitted to the home.

The facility’s electronic system of checking residents’ health records issued a warning pertaining to a possibly dangerous interaction between the two drugs, noting they had the potential to increase the risk of internal bleeding.

According to state inspectors, the nursing staff didn’t acknowledge the warning and didn’t notify the woman’s primary care physician. Days later, the woman was admitted to a hospital emergency room with 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.

The hospital was in the process providing the woman with blood when she died.

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. The home 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 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.

Huffaker’s estate is now suing the home and MGM Healthcare. The companies have denied any wrongdoing and the case is still pending.