Resident deaths lead to fines at three Iowa care facilities

Iowa care facilities have been cited for regulatory violations tied to recent resident deaths.

One of the incidents involves a caregiver who mistakenly dispensed the wrong drugs for a resident, and a nurse who then concealed the full scope of the error from the resident’s treating physicians.

That incident took place at Northgate Care Center in Waukon, which has been fined $10,000 by the Iowa Department of Inspections, Appeals and Licensing for failing to properly assess and treat the resident, who subsequently died.

According to state inspectors, the staff at Northgate mistakenly gave the woman medications intended for another resident — including melatonin to encourage sleep, an antidepressant, an antianxiety medication and an anticoagulant.

Video surveillance footage recorded a short time later showed the resident sitting in a recliner, standing up and immediately falling to the floor. The inspectors’ written description of the footage of the woman’s fall is not entirely clear, with some words apparently missing, but it reads as follows:

7:31:52 — 7:32:04 — The resident stood from her, tripped over her catheter tubing, fell on her left side and hit her head on the recliner all the while Staff A, Licensed Practical Nurse, and Staff B, Certified Nursing Assistant/Certified Medication Aide stood at the nurse’s station.

7:31:59 — Staff A remained at the nurse’s station while Staff B walked around the front of the station with her head positioned down as she looked at an item in her and walked down the north hallway. The resident in site.

7:32:08 — The resident stood from the reclined electric chair.

7:32:13 — 7:32:23 — Staff A casually walked to the resident positioned on the floor and held out her hand toward the resident.

Inspectors say the staff walked the resident to the dining room without first assessing the woman’s injuries. At 9:21 p.m., after the woman complained of pain, an ambulance crew arrived and took her to a hospital where an X-ray indicated she’d sustained a broken leg.

According to inspectors, the resident’s family chose to forgo surgical intervention, which led to hospice care and, at some unspecified point over the next few days, the resident’s death.

According to the inspectors’ report, Staff A, the licensed practical nurse, admitted that after the resident was taken to the hospital, she called the emergency room to report the resident had been given only one incorrect medication — not four — shortly before the fall.

“When asked why she had not told the truth in the beginning, Staff A responded by stating, ‘Because I knew I was wrong,’” the inspectors’ report states.

Other deaths trigger $500 fines

The other recent care-facility deaths that have resulted in state fines are:

REM Iowa in Coralville: This care facility has been fined $500 for failing to provide adequate supervision for a 30-year-old male resident of the home who was diagnosed with a severe intellectual disability and autism.

According to state inspectors, the staff at the home found the man unresponsive in his bed at about 6:55 a.m. June 30. He was pronounced dead at 7:35 a.m., with the death certificate listing the cause of death as natural causes related to complications associated with epilepsy.

State inspectors allege the home failed to have checked on the man at least once every 30 minutes, but that he had not been checked after receiving his morning medication at 6:18 a.m.

Harmony House Health Center in Waterloo: This facility has been fined $500 for failing to coordinate and integrate necessary supports for a 29-year-old male resident with severe intellectual disabilities, autism and a history of eating non-food items.

State inspection reports indicate the man was found on the floor of the facility at 5:55 a.m. Oct. 5, and was pronounced dead 20 minutes later. Inspectors reported the medical examiner’s office indicated the man had two gloves in his stomach and one lodged in his trachea that blocked his airway, as well as a subdural hematoma sustained in a fall.

Inspectors alleged that despite the man’s documented history of eating cloth, paper, gloves, bugs, towels and virtually anything he found on the floor, the home was unable to produce a behavioral assessment that spoke to the man’s habit of ingesting non-food items.