Good Shepherd Health Center in Mason City. (Photo via Google Earth)
A resident of a Mason City nursing home died in August after sustaining numerous injuries that doctors described as suspicious in nature, according to state records.
As a result of the incident, the Good Shepherd Health Center has been cited by the state for failing to provide residents with adequate nursing services, as well as insufficient staffing. Good Shepherd’s staffing levels were also an issue in a 2016 wrongful-death case that resulted in a $900,000 judgment against the facility.
Although a proposed state fine of $8,750 is being held in suspension by the state, the home’s administrator, Kimber Kleven, said Thursday the facility is currently appealing the state’s recent findings through an informal dispute-resolution process.
State records indicate a male resident of the Good Shepherd Health Center fell to the floor shortly after 5 p.m. on Aug. 13 and immediately complained to the staff of pain in his ribs. According to a report filed by state inspectors, the registered nurse who was on duty failed to immediately evaluate the man and opted not to have him sent to the hospital for an evaluation.
The nurse reportedly told inspectors that although nursing supervisors typically assess residents after a fall, at times that doesn’t happen because there is only one supervisor in the building and 165 residents.
Doctor had ‘never seen an injury so severe’
An hour after the man fell, he spoke to his daughter by phone and informed her of the incident. Inspectors allege that conversation led to a request by the man’s daughter to have her father sent to the hospital for an evaluation.
When EMTs arrived, about three hours after the fall, they reportedly transferred the man from his wheelchair to a gurney by grabbing him under his arms and lifting him up as he cried out, “It hurts, it hurts.”
According to the inspectors’ report, the EMS crew didn’t use emergency lights or a siren while transporting the resident to the hospital, with the crew explaining that “extensive studies” suggest that emergency lights and traveling fast “are more detrimental to the patient” and the use of sirens “cause more accidents.”
At the hospital, the man was admitted with fractures in his vertebrae, left clavicle and shoulder; 14 separate fractures among his ribs; a punctured and collapsed lung; and trapped air in his chest, neck and the sac of tissue surrounding his heart — injuries the hospital staff felt were inconsistent with the facility’s description of the fall. The man died four days later, on Aug. 17.
According to the inspectors’ report, the emergency room physician said he had never seen someone who had a ground-level fall sustain those types of injuries and was concerned with the three-hour delay in medical treatment. The inspectors’ report also states that the doctor went on to say that he had dealt with a lot of trauma as an emergency room physician and had “never seen an injury so severe and it struck him as suspicious…. The seriousness of the injuries and reluctance of the staff post-fall (to send the man to the hospital) struck him as odd.”
The physician reportedly questioned what “any reasonable person” would have done in such a situation,” adding that by the time man arrived in the emergency room, he physically “blew up” as air leaked from his lungs into the innermost layer of skin.
“When informed it took three hours from the fall until the facility called the ambulance,” inspectors reported, “the emergency room MD responded that had been totally unreasonable.”
While looking into the matter, state inspectors also investigated five complaints against the facility, all of which were substantiated. Inspectors reported that as they stood by and observed, a nurse at the facility reportedly spoke to a resident’s family in a derogatory tone, rolled her eyes and made negative facial expressions.
One resident’s daughter complained that at times it took the staff well over an hour to answer call lights, which resulted in her father being left to sit in urine-soaked clothing. Another resident complained of being left on the toilet for up to 45 minutes, adding that such delays occurred during every shift, inspectors reported.
The home was cited for violations related to residents’ rights, quality of care, medication and treatment and insufficient staffing.
CEO has opposed new staffing mandate
Currently, the Good Shepherd home has a three-star, or average, rating from the Centers for Medicare and Medicaid Service for its staffing levels. Overall, it has a two-star, or below average, rating from CMS.
The home is independently owned by the nonprofit Good Shepherd Geriatric Center of Mason City, which is led by CEO Ian Stockberger. According to the organization’s tax returns, the organization paid Stockberger $284,431 in 2023, an amount that included a $15,000 bonus, and paid Kleven, the home’s administrator, a total of $164,604.
Last year, Stockberger wrote to CMS to state his opposition to nursing home staffing-level mandates that were approved in April of this year.
Stockberger wrote that the mandates were “unaffordable” and stated that prior to the pandemic, Good Shepherd had 320 employees. In 2023, he wrote, the home was operating with only 260 employees while “begrudgingly” relying on more costly temporary workers provided by staffing agencies.
“The use of staffing agency costs us approximately $1.5 million per year above what we would pay normal employees if they existed,” he wrote. “Not only is this financially breaking us, we are now facing increased pressure to maintain staffing levels.”
On Wednesday, Iowa Attorney General Brenna Bird joined industry lobbyists and attorneys general in 19 other states in suing the federal government to block the implementation of CMS’ new staffing-level mandates.
Staffing levels cited in wrongful death lawsuit
In February 2015, a resident of Good Shepherd, Maria O’Brien, along with her children, sued the home, alleging inadequate care. After O’Brien was admitted to a hospital for dehydration and pressure sores, she died and the lawsuit was amended to include additional allegations of neglect.
A nine-day trial was held in 2016. Court records indicate there was testimony that the recurring quality-of-care complaints made by O’Brien’s daughters had earned them the name “the Bitch Sisters” within the home.
Stockberger and the director of nursing each testified that they had fielded complaints from the staff that there were not enough workers to meet residents’ needs. A former charge nurse for the home testified that she had resigned because the lack of staff meant she was unable to meet the needs of residents in her care.
A jury found Good Shepherd was negligent and awarded the family $150,000 in compensatory damages, plus $750,000 in punitive damages due to a finding of willful and wanton neglect.
The home appealed that decision, but it was upheld by the Iowa Court of Appeals , which said the home’s “inadequate care of O’Brien continued despite the prevalence of adverse consequences — continued falls, significant weight loss, deterioration of overall health, and dehydration — which became fatal. Good Shepherd was aware of these adverse consequences and took no steps to remedy them. Good Shepherd’s conduct evinced an indifference to, or a reckless disregard of, the health or safety of others.”
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