Care facility fined $9,000 for infection, death
by Clark Kauffman, Iowa Capital Dispatch
November 11, 2024
An Iowa care facility has been fined $9,000 for failing to treat a bed sore that contributed to the death of a resident.
State records indicate a woman was admitted to the Elkader Care Center on Oct. 4 with a shallow, open sore on her backside. However, the care plan developed by the Elkader home allegedly failed to include any procedures for repositioning the woman on a regular basis to ensure the sore didn’t worsen, and the staff allegedly failed to assess the wound.
On Oct. 10, a nurse noted the wound had increased in size and was emitting an odor. Later, the nurse allegedly told state inspectors she should have performed a more complete assessment and informed the woman’s doctor, although she did neither.
On Oct. 15, less than two weeks after her admission to the Elkader home, the woman was transported to a hospital emergency room after developing sepsis — a life-threatening infection. At that point, the wound had worsened to the point where a nurse practitioner described it for inspectors as “shocking.”
On Oct. 18, the resident died, with the cause attributed in part to sepsis related to the open wound. The resident’s primary physician allegedly told inspectors the wound could have been avoided or minimized had the staff informed her of the woman’s condition.
State records indicate the Elkader facility has yet to pay the $9,000 fine imposed by the state.
Other Iowa nursing homes recently cited for quality-of-care issues include:
— Medication errors: Clarion Wellness and Rehabilitation Center, which was cited for failing to administer doctor-ordered medications to residents. In one case, the home had received a resident’s medication that was intended to slow the progression of his cancer, but for six weeks it failed to administer the drug and failed to notice the supply of the medication wasn’t being depleted.
According to state inspectors, the resident subsequently showed signs of elevated proteins of the kind that are produced by cancer cells. In addition to the medication error, the home allegedly failed to inform the man’s family or doctor of the error once it was discovered, and didn’t complete an internal investigation as to how the error occurred.
The operations manager at the cancer center that was treating the man allegedly told inspectors that the Clarion facility’s failure to provide the medication could accelerate the cancer’s progression and prove fatal. The center’s advanced registered nurse practitioner agreed, and reportedly told inspectors the man had already undergone two stem-cell transplants and she didn’t want to put him through that again.
In a separate medication-error case, a female resident of the Clarion home was mistakenly given her roommate’s round of six separate medications, rather than her own. The error was caught only after the resident who should have received the drugs noticed that the assortment of pills she had been given didn’t look like hers. At that point, the staff realized the two sets of medications had been inadvertently swapped.
The state proposed, and then held in suspension, a $7,000 fine so that federal regulators could determine whether to impose a penalty of their own.
— Missed labs: The Rehabilitation Center of Des Moines, which was cited for failing to properly obtain the doctor-ordered blood work for a resident who then had to be hospitalized. Inspectors allege that in August the resident’s doctor ordered the staff at the Rehabilitation Center to re-check the resident’s sodium and potassium levels in one week. The order was somehow missed and on Aug. 27, the resident was transported to the hospital and admitted with critically high sodium levels. The state has held in suspension a $5,200 fine.
— Abuse: Rose Haven Nursing Home in Marengo, which was cited for failing led to follow its own policies on resident abuse after it was discovered that a resident’s narcotic medication was missing and may have been replaced by a look-alike tablet of acetaminophen. The home was fined $500.
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