Care facilities cited for death, abuse, incompetent staff and medication errors

The Iowa Department of Inspections, Appeals and Licensing, which oversees the enforcement of nursing home regulations, took over responsibility for many of Iowa’s licensing boards in July 2023. (Photo illustration via Getty Images; logo courtesy of the Iowa Department of Inspections, Appeals and Licensing)

Six Iowa care facilities have been cited in recent weeks for medication errors, incompetent staff, resident abuse and a death, according to state records.

Park View Homes in Sioux City, a 45-bed facility for people with disabilities, was recently fined $8,000 by the state as a result of an inspection that took place over the course of three months, ending in late July.

The inspection was triggered by a complaint and three self-reported incidents, and resulted in the home being cited for five federal regulatory violations and one state regulatory violation.

According to state records, two direct support professionals working in the home found a 68-year-old female resident of the home in her bed, unresponsive and not breathing, during a 5 a.m. check on May 5. No one on staff attempted cardiopulmonary resuscitation, as the home’s policy dictated, and the resident was pronounced dead at 5:20 a.m.

One of the direct support professionals reportedly had a CPR certification that expired in January 2024. The other direct support professional told inspectors she couldn’t recall whether she’d received training on the home’s medical emergency policy and said she did not know whether the deceased resident had a do-not-resuscitate order in place.

Both workers said they were unsure as to how they should administer CPR on people who had feeding tubes in place, such as the deceased.

According to inspectors, the resident had been awake in the hours before her death and had been “crying throughout the night” as if she was in pain. One of the direct support professionals reportedly told inspectors that because the “on-call nurse” that night wasn’t actually a nurse and wouldn’t know what to do he made no attempt to contact her about the resident’s condition.

Inspectors later determined the on-call nurse was not a licensed nurse but a certified medication aide who passed medications at the home. The resident’s cause of death was reported to be hypoproteinemia, indicating low protein in the blood.

According to the inspectors’ reports, the home’s failure to have sufficient, competent staff placed residents in immediate jeopardy, but the situation was corrected on May 10. However, the same reports indicate the medication aide remained as the “on-call nurse” until May 13 when the director of nursing returned from vacation.

In June, while the state inspection at Park View Homes was still underway, the facility was cited for two federal violations and one state violation. That resulted in a $5,000 fine for failing to provide residents with their prescribed food.

The home had allegedly fed one resident fettuccini with whole shrimp, despite dietary restrictions that indicated he was to be given only small, bite-size food pieces to prevent choking. The resident subsequently choked on his meal, was unable to speak, and had to be given the Heimlich maneuver to clear his airway.

Other Iowa care facilities recently cited for violations include:

— Fort Dodge Health and Rehabilitation , which was fined $500 for failing to report resident abuse to state regulators. A staff member allegedly reported that a certified nursing assistant spoke to a female resident of the home in an abusive manner after the woman had an episode of incontinence. The CNA allegedly told the woman, “We need to get you on the commode so you will stop s—-ing your pants, I don’t have time for this,” and then walked out of the resident’s room.

— Stacyville Community Nursing Home , which was fined $5,000 for giving a resident the wrong medication, resulting in the resident being admitted to a local hospital. The home was also cited for insufficient staffing and failing to have a registered nurse in the building for eight consecutive hours or more, in violation of federal requirements.

According to inspectors, the home had failed to schedule a registered nurse on 10 separate days between February and July. The administrator told inspectors she mistakenly believed the home had been granted a waiver on the nurse-staffing requirement. The $5,000 fine for the medication error has been held in suspension by the state.

— Hillcrest Health Care Center of Hawarden , which was fined $25,500 in July for failing to follow dietary restrictions and repeatedly giving residents meals that posed a choking risk. The home had been cited for the same violation, and fined $8,500, in January. Both the January and July fines have been held in suspension by the state.

— Aase Hagen Home of Decorah , which was fined 4,500 by the state for failing to protect residents from hazards. The violation was tied to injuries sustained by a resident who fell out of a mechanical lift that was being used to transfer the individual in or out of bed. Because this was a repeat violation, the $4,500 fine was tripled to $13,500, and then held in suspension by the state.

— Osage Rehab and Health Care Center , which was fined $7,250 for leaving a resident flat on his back in bed during tube feeding, even after the resident had vomited. The man was subsequently taken to a hospital and admitted to a critical care unit and diagnosed with aspiration pneumonia and septic shock. Two weeks after the incident, the man was still in the hospital and was gravely ill, with possible brain damage caused by oxygen deprivation, according to inspectors. A family member of the resident reportedly told inspectors that in the past he had twice advised the staff to refrain from feeding the man while he was flat on his back, but the staff was “incompetent and failed to listen.” The $7,250 fine has been held in suspension by the state.