Dubuque home cited for placing disabled individuals in immediate jeopardy

A Dubuque care facility for people with disabilities has been fined $13,750 for failing to provide injured residents with nursing services during weekends and evening hours.

The West 32^nd Community Living Home, which is an eight-bed intermediate care facility for individuals with intellectual disabilities, was cited last month for 14 federal regulatory violations and seven state violations.

The Iowa Department of inspections and Appeals determined that residents of the home had been placed in immediate jeopardy due to a failure to ensure timely nursing assessments in response to injuries and medical conditions, a failure to follow policies for the prevention of abuse and neglect, and a failure to ensure adequate supervision of residents.

According to DIA inspectors, there were several incidents of residents being injured without being provided the customary immediate assessment by a nurse. For example, on Feb. 18, a resident broke a window with his head, but a nurse’s assessment of the resident’s condition was not performed until Feb. 27.  And on Nov. 12, 2022, a resident fell in the tub, hitting his head, but a nurse didn’t assess the resident until two days had passed.

A supervisor told inspectors the home had no nursing services after 4:30 p.m. on weekdays and no nursing services on weekends. The home’s licensed practical nurse told inspectors she worked business hours Monday through Friday, and said  injuries were not assessed by the facility outside of those hours.

The inspectors alleged that on Feb. 18, a staff member reported that a colleague had dragged a resident across the floor, by the ankles, to the resident’s room. The resident later complained that his back hurt, and a supervisor discovered rug burns and bruises on the man’s back and shoulders.

The accused worker allegedly admitted that she had pulled the man to his room by his legs, saying she had done so “playfully.” A nurse didn’t assess the resident until 10 days had passed, at which point it was determined there was no need for medical intervention.

The home’s records included material related to an investigation into the incident, but there was no record of the facility conducting any sort of follow-up or providing the state with the required notification, inspectors alleged.

The inspectors also noted a May 26 incident in which a worker attempted to block a resident from entering an office and, when the resident dropped to the floor, the worker shut the resident’s head in the door. Another employee told inspectors she witnessed the incident and believed the accused worker had “purposefully held the office door shut on (the resident’s) head and neck for at least one minute.”

In December, the home documented an incident in which one resident was given another resident’s medication in error. The resident who received the wrong drugs later showed signs anxiety and one of her arms became stiff and rigid. The resident had a seizure and was transported to a hospital for treatment.

After the error was discovered, the staff failed to assess the resident’s condition or check her vital signs. In addition, the home’s quality assurance director confirmed for inspectors that she failed to complete an investigation into the incident.

Inspectors also made note of an incident in which a male resident was left unsupervised outdoors when a lawn service contractor saw the man break the lock off an outdoor electrical box, then begin pulling on the main electrical cable from the air conditioner to the home. The resident’s care plan called for the staff to have the man in sight at all times.

The West 32^nd Community Living Home was also cited for failing to have provided top administrators and supervisors with timely training on dependent adult abuse.

The home’s administrator, Susan Freeman-Murdah, could not be reached for comment. The facility is owned and managed by the nonprofit organization Area Residential Care Foundation of Dubuque.

The organization operates three separate eight-bed homes in neighborhoods throughout Dubuque, and says it maintains “staff ratios of 1:2 or 1:3 during the consumers’ most active portion of the day,” and that each of the three homes “also has overnight, awake staff members seven days a week.”