Aide squirts glue into resident’s eye at troubled Iowa care facility

An Iowa nursing home with a history of serious regulatory violations may be facing federal penalties for squirting fingernail glue into a resident’s eye.

According to state inspectors, a male resident of the Aspire of Gowrie care facility in Webster County approached a nurse aide in the dining room of the home during the evening of Nov. 11, 2022. The man handed the aide a small bottle he had picked up from his bedside table and asked the aide to help him with his eye drops.

Without first confirming the contents of the bottle, the aide began administering fluid from the bottle to the resident’s right eye.

The resident immediately complained of pain and burning, at which point the aide looked at the bottle and saw that she placed fingernail glue into the man’s eye. A team of emergency medical technicians was summoned to the home and flushed the resident’s eye for at least 25 minutes, at which point the man’s “eyelids broke apart,” inspectors reported.

In the meantime, the nurse aide who had mistakenly put the glue into the resident’s eye left the facility because her shift had ended. According to inspectors, she was overheard talking on the phone as she left the building, saying, “You wouldn’t believe what just happened.”

The man was treated for pain and vision-related issues over the course of the next two weeks. State inspectors noted that according to the facility’s own policies, only a licensed nurse should have administered medications and that the man had not been prescribed any eye drops.

“Boy, it sure hurt when the fingernail glue was placed into my right eye,” the man later told state inspectors. He reportedly stated that while his doctor had assured him his eye wouldn’t bother him “forever,” he continued to have blurry vision.

He told inspectors he had no idea why there was fingernail glue on his bedside table but added that he felt sure one of the workers must have left it there.

The Iowa Department of Inspections and Appeals cited the home for 15 state and federal regulatory violations, including failure to meet professional standards, failure to offer activities to meet residents’ needs, failure to employ competent nursing staff, failure to prevent significant medication errors, inadequate infection control, and inadequate COVID-19 testing and supplies.

DIA fined the facility $5,250 for failing to keep residents safe, then tripled that amount because it was the second serious safety violation during the past 12 months. The fine was then held in suspension so that the Centers for Medicare and Medicaid Services could determine what penalties, if any, to impose. As of Wednesday, CMS had yet to report taking any action against the home.

With regard to the COVID-19 issues, an unvaccinated worker told inspectors she was tasked with caring for a COVID-positive resident but that she and her colleagues could not find any of the required masks for staff to wear. She called and texted the home’s director of nursing but never received a response, she said, and so she and colleague wound up caring for the resident without the required masks, placing herself and the residents she subsequently cared for at risk. Two workers at the home subsequently tested positive for COVID-19, according to inspectors.

The home was also cited for failing to test residents and staff for COVID-19 even after one resident had tested positive. The director of nursing told inspectors that she believed, contrary to federal regulations, that one new case of COVID-19 did not constitute an outbreak.

Dozens of violations found by inspectors 

Over the past 14 months, Aspire of Gowrie has been cited for 67 state and federal regulatory violations. Just one day before the glue incident, DIA imposed, and then suspended, a $7,000 fine against the home for resident-safety issues.

Those violations were related to a bipolar male resident who repeatedly made sexual demands and sexual advances on the staff and residents. In June 2022, a nurse saw him touching the breasts of a female resident. The facility notified the police, but the female resident’s family declined to pursue the matter.

Over the next four months, the staff documented numerous additional incidents in which the man demanded sexual favors of others, physically threatened those who rejected his advances, entered the rooms of female residents and put his hand between a worker’s legs. After being admonished, the man “just laughed and moved on to another female,” inspectors reported.

One female resident allegedly told inspectors that the man was sexually aggressive and that “if he could get to you, he would.” Another female resident reportedly told inspectors she was concerned the man would come into her room and that she would not be able to get away from him. A third resident allegedly stated that the man had touched workers and residents so many times it was hard to remember every instance.

In November 2021, CMS imposed a $20,000 fine against the home. That fine followed findings related to the home’s failure to assess residents for signs or symptoms of COVID-19 after an individual at the home tested positive for the virus. At least three of the residents who weren’t assessed later died of COVID-19.

A registered nurse at the home acknowledged not having performed COVID-19 assessment screenings on residents, allegedly telling inspectors it would have taken 24 hours and that she “would never get home.”

The home was cited for insufficient nursing staff, with inspectors noting that some residents hadn’t received showers for several weeks. Although the home had 22 residents, there were nights when only two people were working, and only one of the two was capable of providing any type of nursing care. The other worker was the home’s interim administrator, and she lacked even a nurse’s aide certificate. By working the overnight shift, outside her normal work hours, the interim administrator was eligible to collect bonus pay, inspectors noted.

The home’s new administrator, Tara Behrendsen, said Wednesday that the facility has re-educated the staff and is addressing all of the issues raised by inspectors.

Aspire of Gowrie currently has CMS’ lowest possible rating for overall quality, health care inspections and staffing levels. According to the federal agency’s Care Compare website, 0% of both staff and residents are reported to be currently up to date on their COVID-19 vaccinations.

CMS records indicate the home is a for-profit venture owned by Black Hawk Healthcare, a limited liability corporation, and that Bruce Wertheim of Beacon Health Management in Tampa, Florida, has managerial and operational control of the home. Wertheim could not be reached for comment Wednesday.

Aspire of Gowrie is part of a chain of several Iowa nursing homes. Earlier this year, CMS imposed at least $289,150 in fines against the Aspire of Primghar home in O’Brien County, according to DIA. That fine has since been reduced to $99,600, according to state records.