State cites Iowa care facilities for death, injury and resident abuse

State cites one home for a July 2022 death after Iowa Capital Dispatch report

By: - February 7, 2023 5:58 pm

Trinity Center at Luther Park in Des Moines. (Photo via Google Earth)

Several Iowa care facilities for the elderly and disabled have been cited recently for death, injury and resident abuse.

The Iowa Department of Inspections and Appeals has proposed a total of $105,250 in state fines against the six homes. All but $1,000 of those fines are being held in suspension while regulators at the Centers for Medicare and Medicaid Services determine whether to impose federal fines in place of any state penalties.

 Resident death: Trinity Center at Luther Park in Des Moines has been fined $9,750, held in suspension by the state, as a result of a female resident suffocating on food and being denied basic life support in an emergency. The death took place last July. DIA officials have said the agency didn’t investigate the death until December of last year — one week after the Iowa Capital Dispatch reported it — because they were unaware of it.

The inspectors’ report indicates a resident’s family member found the woman unresponsive in her bed at lunch time with food particles scattered on the bedding.  The staff allegedly initiated CPR, but performed only chest compressions, without clearing the woman’s airway and without performing mouth-to-mouth respirations.

EMTs were summoned to the home but were initially routed to the wrong location and so 20 minutes passed before they could suction the woman’s airway and dislodge what they later described as “considerable amounts of food.” The resident was pronounced dead a short time later, with doctors listing asphyxiation as the cause of death.

The home was fined an additional $7,500 for failing to provide the woman with the required soft, ground-meat diet that had been prescribed. The facility was unable to provide inspectors with the written meal ticket showing precisely what the woman had been served just before she died, as those records had been thrown away during the intervening five months.

State unemployment records show a former cook at Trinity, Richard A. Kerr, was fired for having given the woman pulled meat instead of ground meat. Administrative Law Judge Carly Smith denied Kerr’s subsequent request for unemployment benefits, stating that “as a result of (Kerr’s) failure to follow directions, a resident choked on the food, was hospitalized and died.”

“He is hitting everyone … We should not have to live in danger every day.

– Resident of Cedar Falls Health Care Center

Resident abuse: The Davis Care facility in Bloomfield, which houses people with intellectual disabilities, was fined $500 for resident abuse. According to state inspectors, a certified nursing assistant at the home, which is owned by Davis County and managed by Optimae Life Services, sprayed water in the mouth of a female resident, put a washcloth over the resident’s mouth, put hot water in the resident’s ears, and told her to shut up, all while providing the resident with a shower.

The alleged victim told inspectors she had a pinched nerve in her back and the CNA bumped into her several times during the shower, causing pain. Another worker at the home told inspectors she saw the CNA spray water in the woman’s mouth “a couple times with the shower head and then place a towel in her mouth.”

The worker who witnessed the incident allegedly turned to another employee who was present, and said, “I can’t witness this,” and walked away. The other employer’s description of the incident matched that of the alleged victim and the worker who walked away.

The director of nursing told inspectors that about one month before the incident, the accused worker and a colleague were written up for having dragged a soiled resident across a floor, out of one room and onto another, using a blanket. Davis Care was cited for failing to investigate the abuse allegations in a timely fashion, failing to separate the accused worker and the alleged victim, and failing to train the staff on abuse.

Resident abuse: One Vision Oak House in Fort Dodge, an intermediate care facility for people with intellectual disabilities, was fined $500 for failing to report to the state allegations of abuse. The inspectors’ written report, which is not entirely clear, indicates two direct support professionals at the home were abusive toward a resident who could sometimes be hyperactive.

The two workers allegedly yelled at the man, ordering him to “come here.” On at least two occasions, the workers “sat and blocked the” doorway of a room to keep the resident from leaving, with the resident continuously jumping and screaming and tapping one of the workers on the shoulder as if to get their attention.

The workers allegedly blocked the doorway or sat with their feet propped against the closed door to keep the man confined in the room. A temporary staffer reported the matter to a nurse who in turn reported it to a team leader – a claim the team leader denied when speaking to inspectors.

Resident abuse: Cedar Falls Health Care Center was fined $17,000, held in suspension by the state, for failing to keep residents safe and failing to protect residents from an individual with a known history of violent behavior.

A male resident of the home told inspectors one his fellow residents had approached him recently, indicating he was angry over a remark that had been made, and then punched him in the left eye, saying, “There you go.”

A worker later reported that just before the attack, she had seen the two men standing near each other, with one of them punching the air and screaming at the other, “I’m going to kill you! I’m going to kill you!”

A female resident of the home told inspectors the alleged attacker was dangerous, stating, “He is hitting everyone … We should not have to live in danger every day. The staff lets him do whatever he wants to do because they are all afraid of him.”

Another female resident told inspectors she was “tired of living in fear” every day.

Resident injury: Cedar Falls Health Care Center also was fined $28,500, held in suspension by the state, for failing to provide a resident with necessary care and placing residents in immediate jeopardy.

A resident of the home told inspectors that recently, over a period of four days, he’d had trouble breathing and was slurring his words, but the staff nurse didn’t check on him. On Dec. 1, 2022, an aide took the man to the home’s front office because he couldn’t breathe and wanted to make a phone call to summon help. The director of nursing later acknowledged to inspectors that she did not assess the man when he was brought to her office.

A worker at the home told inspectors she had informed a nurse that one of the man’s legs was very swollen but the nurse “blew it off.” When the man later had an extremely high blood pressure and was having trouble breathing, the same nurse “lied” and indicated the man’s blood pressure was fine, the worker said.

A nurse who came on duty later that same that day took the resident’s blood pressure and sent the man to the hospital, where he remained for the next two weeks.

At the hospital, the man had a stroke caused by dangerously high blood pressure that was in the emergency range. Doctors “removed 18 pounds of fluid” from the man’s body using diuretics. The resident’s advocate told inspectors that prior to the man being hospitalized, he “looked like the Hulk,” as one arm had swollen to three times its normal size and both legs were very swollen.

Resident safety: Risen Son Christian Village in Council Bluffs was fined $27,000, held in suspension by the state, for violations related to resident safety.

On Dec. 1, at around 1:30 p.m., a female resident with a history of wandering and cognitive issues left the building in a shirt, pants and socks in 46-degree weather. Although the resident wore an alarm bracelet and exited through an emergency-exit door, no alarms sounded and the staff remained unaware the resident had left until a worker noticed her standing outside.

“It makes me feel like they don't care if I can breathe or not.”

– Resident of Lantern Park Specialty Care

Inadequate nursing services:  Lantern Park Specialty Care in Coralville was fined $9,000, held in suspension by the state, for failing to provide residents with the required nursing services.

A female resident of the home with a tracheostomy – a tube and surgical hole in the neck that provides an alternative airway – told inspectors she had been in the hospital three times on an emergency basis due to her airway drying out and becoming clogged. The last time it happened, she said, she was so dry that her lungs were bleeding.

The woman told inspectors she had to wait up to two hours to have her airway suctioned so she could breathe, adding, “It makes me feel like they don’t care if I can breathe or not.”

While inspectors were in the building investigating the matter, they observed that there were no suction catheters or suction equipment at the woman’s bedside to assist in keeping her airway clear, and the humidifier near her bed was switched off, contradicting physicians’ orders. A nurse told inspectors, “My concern is that we need more training and only one nurse knows how to change her trach.”

The assistant director of nursing reported that no one there had asked for any training on the process and no training was offered.

An additional $5,500 fine, also held in suspension, was proposed due to the home’s failure to manage residents’ pain. While inspectors watched, a resident complained to a nurse that her pain was an “eight” on a scale of one to 10.

“I don’t know if we have Lidocaine (pain reliever),” the nurse responded. “I will dig around in the supply room.”

An hour later, inspectors reported, the nurse returned and informed the resident she couldn’t find any Lidocaine. She then left the room without assessing the resident’s pain levels or offering any other form of treatment. Fifteen hours later, the resident was still waiting for the Lidocaine. It was later determined the supply had been replenished but never administered to the resident.

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Clark Kauffman
Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing.