State-run Glenwood home for the disabled is cited again for violations

For the seventh time in the past 19 months, a state-run home for the disabled is facing fines for inadequate care. Two of seven violations cited by inspectors have involved the death of residents.

According to inspection reports from the Iowa Department of Inspections, Appeals and Licensing, a worker at the Glenwood Resource Center for individuals with disabilities left her purse in a common area of the home on the morning of Aug. 14, 2023.

Inspectors said they later reviewed surveillance video showing a male, 42-year-old resident with severe intellectual disabilities taking the purse to his room. About 25 minutes later, two employees entered the man’s room and saw the purse on the man’s dresser. The purse’s owner realized her bottle of hydrocodone was empty, though it should have had about four pills left in it. The resident had white powder on his hands and around his mouth, according to inspectors.

Soon after, the man became lethargic and his oxygen levels began to drop. The staff administered a dose of Narcan and called 911 to have the man transported by ambulance to a hospital emergency room. The man was given two additional doses of Narcan at the hospital, was admitted overnight, and was discharged back to Glenwood the next day, according to inspectors.

In citing Glenwood for failing to ensure the staff followed facility policy in securing personal belongings that could be harmful to residents, inspectors noted that the resident who had overdosed on hydrocodone had a recent COVID-19 infection “resulting in critical lung illness and hospitalization for a month.”

Workers told inspectors other employees would at times leave personal bags, purses and backpacks in common areas that were accessible to residents. The inspections department concluded residents had been placed in immediate jeopardy due to the facility policy not being followed. The situation was corrected within 24 hours when Glenwood developed and implemented a plan to re-train all of the staff.

The facility was fined $7,500.

As part of their recent visit to Glenwood, state inspectors also cited the home for an incident in which a worker held shut the door to a living-room area to keep a 60-year-old, wheelchair-bound resident confined in a hallway. Other workers reported that while their colleague held the door shut and refused to intervene, the resident, who was profoundly disabled, began yelling and hitting himself in the face and head, resulting in multiple scratches and an open area on his face.

Other Glenwood fines stemmed from resident deaths 

In June 2023, inspectors fined Glenwood $2,500 for failing to consistently ensure each client received the services outlined in their individual care program.

In February 2023, the home was fined $10,500 for providing a resident with the wrong medication, resulting in a hospitalization, plus $5,250 for failing to ensure residents were safely transferred using mechanical lifts.

In 2022, the Glenwood Resource Center was fined on four separate occasions.

In January of that year, it was fined $2,750 for failing to provide services according to residents’ care plans and failing to report potential abuse to the state.

In May 2022, the home was fined $10,000 after a resident with acute dehydration died.

In July 2022, the home was fined $5,037 for failing to give the staff adequate training and supervision.

In August 2022, the home was fined $7,500 for failing to intervene when necessary to promote residents’ health. In that case, a resident died after the staff failed to intervene when his heart rate dropped significantly.

The western Iowa home is run by the Iowa Department of Health and Human Services.

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.