The Keota Health Care Center. (Photo via Google Earth)
An eastern Iowa nursing home has been cited for 33 regulatory violations, some of which allegedly contributed to the death of a resident.
The 33 state and federal violations cited at the 26-resident Keota Health Care Center represent an extraordinarily high number of violations for a care facility of that size and are detailed in a 174-page report authored by state inspectors.
The citations are for issues related to insufficient staffing levels, resident abuse, medication errors, quality of care, dietary services, infection control, resident safety and numerous other issues.
As a result of the violations, the Iowa Department of Inspections, Appeals and Licensing has proposed six fines against the home totaling $37,750, but is holding those fines in suspension so the Centers for Medicare and Medicaid Services can determine whether to impose a federal fine in their place.
One of the alleged violations is tied to allegations that the home failed to provide adequate assessments and interventions for a female resident who apparently fell at the home and was later found face down on the floor with a bleeding head wound.
The home allegedly faxed information about the fall to a physician shortly after the woman was found on Sept. 7, but the physician didn’t respond until Sept. 9. The woman’s overall condition declined over the following several days. On Sept. 22, she was transferred to a hospital after exhibiting stroke-like symptoms and was diagnosed with a large subdural hematoma, or brain bleed.
The woman died on Sept. 29, with the immediate cause of death listed as complications due to an accidental fall. The home’s director of nursing allegedly told inspectors the woman should have been sent to the hospital’s emergency room the day of the fall due to her obvious head injury.
Staff to nurse: ‘We are too busy’
The home was also cited for failing to protect residents from sexual abuse. Inspector noted several instances of a female resident who had severe cognitive impairments being touched, grabbed and groped by a fellow resident. Another resident of the home was alleged to have hit one resident, grabbed and scratched another, slapped a third resident, and slapped and pinched a fourth resident.
In addition, the home was cited for failing to conduct thorough investigations into allegations of abuse and resident injuries of unknown origin, despite staffers being aware of one resident’s complaint of being handled roughly by at least one of the workers. That same resident later sustained an unexplained “huge” shoulder injury that included a displaced fracture of the upper arm, inspectors reported.
The home was also cited for a medication error rate of 12%, which was more than double the allowable maximum of 4.9%.
A hospice nurse reportedly told inspectors that for a while, whenever she came to visit a particular female resident, the woman would be “saturated in urine with a dirty brief on.” The hospice nurse also reported that on one occasion, she found the woman lying in bed, flat on her back, with a lunch plate resting on her abdomen and food in her hair, with “a very strong urine odor” about her.
A registered nurse at the home reportedly told inspectors about a female resident being left naked in what was described only as a “pee bed,” adding that it “looked horrid.” The woman was cold and the home’s certified nursing assistants initially refused to dress the woman and change her bed linens, while the home’s director of nursing allegedly stated the woman had the right to be naked so the staff should just pull the curtain around her bed.
The nurse allegedly told inspectors that when she bent down to give the resident her medicine, she discovered that her “knee was in pee in the resident’s bed.” The nurse allegedly reported that when she turned to the staff and told them, “We can’t have this,” the response was, “We are too busy.”
Inspectors also noted that the home’s policy called for infection control in the facility to be overseen by a certified infection preventionist. However, the home was unable to produce any evidence of a certified infection preventionist being employed there.
Keota Health Care Center is managed by a Florida company called Mission Health, according to state records.