Resident injuries continue to plague the state-run Glenwood Resource Center

For the second time in three months, the state-run Glenwood Resource Center has been fined for regulatory violations related to resident injuries.

It marks the sixth time since January 2022 that the facility has been fined by state inspectors.

Last year, the state announced plans to relocate Glenwood’s residents and close the facility by the end of 2024. Several months ago, the U.S. Department of Justice announced it had reached a settlement with the state of Iowa to resolve allegations concerning resident care at Glenwood. The DOJ had alleged the state was causing harm to residents through “uncontrolled and unsupervised experimentation” on residents, as well as inadequate physical and behavioral health care.

The western Iowa home for people with disabilities is run by the Iowa Department of Health and Human Services.

State records indicate that on March 27, a male resident of the home got out of bed at around 4:40 a.m., went into the bathroom and fell and hit his head, which resulted in a bleeding wound. After the man’s eye began to swell shut during an evaluation by the staff, he was taken by ambulance to a nearby hospital where doctors closed the head wound with three staples.

According to the state inspectors’ report, Glenwood’s assistant superintendent reported that a review of closed-circuit video revealed that a residential treatment worker assigned to check on the resident every 30 minutes did not do so throughout the night.

The Iowa Department of Inspections and Appeals has fined the home $2,500.

In March, the facility was cited for two medication errors and fined $10,500. In addition, the facility was fined $5,250 for failing to ensure the staff correctly used the mechanical lifts that are designed to safely move residents who can’t stand or ambulate on their own.

The first of the two medication errors was discovered in early December when a worker noticed a male resident was “groggy and stumbly” and appeared intoxicated. The staff then noticed the man’s medications for the previous afternoon were still on hand, indicating they hadn’t been dispensed, while another resident’s medications were missing, even though that individual had been discharged.

It was then determined the male resident, while receiving none of his own medications, had been given the drugs intended for the discharged resident. The man was taken to a hospital where it was determined he had a “dangerous” level of valproic acid in his system, according to inspectors. He was treated with intravenous fluids, held for observation, and then returned to Glenwood.

The second of the two medication errors occurred a few weeks later, on Christmas Eve, when a worker accidentally gave a female resident two 100-milligram doses of Clozapine, a drug commonly used to treat schizophrenia, rather than a single 100-milligram dose. The resident was taken to a local hospital by ambulance and kept there for observation for two hours before being returned to Glenwood.

At the time, Glenwood was also cited for an accident that resulted in a serious injury to a resident. According to inspectors, a female employee was in the process of using a mechanical lift to hoist a resident into the air and place him in a chair when the man slipped out of the device and fell to the floor.

The resident was taken by ambulance to a hospital where he remained in the intensive care unit for two days before being returned to Glenwood.

Last August, Glenwood was cited for having failed to notify a nurse when a female resident’s heart rate dropped to a dangerous level. The resident was later found unresponsive was rushed to a hospital where she was pronounced dead. The home was fined $4,785.

Last July, Glenwood was fined for $5,037 after a 48-year-old male resident was found in bed suffering from a hypoxic episode — a life-threatening lack of oxygen. A worker noticed the resident’s skin was gray, lips were blue and he was gasping for air. The worker discovered the mechanism used to deliver his bottled oxygen had been switched off by the staff.

In May 2022, Glenwood was fined $6,500 after a resident of the home died of septic shock related to acute dehydration.

In January 2022, Glenwood was fined $2,250 after inspectors said a residential treatment worker had yelled at a female resident of the home and shoved a plate in her face.