‘Help me’: Iowa nursing home that’s among the nation’s worst faces no state fines

Among the violations state inspectors say they found in March:

• A medication aide at the home told inspectors that on Dec. 12, 2020, he looked in on a COVID-19 patient and the resident appeared happy and smiling, with no concerns. Two hours later, the aide said, he saw the director of nursing emerge from the resident’s room, saying the resident was dead. About 10 or 15 minutes later, the aide said, he went into the resident’s room and the director of nursing asked him what she should do because the resident’s status was “full code,” indicating CPR should be attempted. After another 30 minutes passed, a third worker arrived on the scene, initiated CPR and summoned an ambulance. The resident could not be revived. The director of nursing later told inspectors she had waited only a “few minutes” to initiate CPR. The home’s administrator told inspectors the director of nursing was fired after the incident.
• While inspectors watched, a female resident hollered “help me” and “hurry up” from her bed on the morning of March 23. The door to the resident’s room was closed, inspectors said, but the hollering could be heard at the nurses’ station down the hall. Twenty-three minutes later, a nurse arrived, pushing a medication cart down a nearby hallway. Although the resident continued to call for help, the nurse did not stop to check on the woman. The resident continued to call for help until 47 minutes had passed and two workers entered her room.
• A male resident of the home reported that he had twice summoned a nurse to his room to empty his urinal so he could relieve himself. In both instances, the worker refused and the man eventually soiled himself, later telling inspectors he felt belittled and ashamed.
• The home failed to notify residents’ physicians of significant unexpected weight loss, with one resident dropping from 163 pounds to 146 pounds in 30 days.
• The home employed a nurse aide with convictions for theft and assault without having the worker cleared for employment by the state.
• Inspectors reviewed five patient files and found that in all five cases, the home failed to ensure a physician saw the resident at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Some residents had not been seen by a doctor for six months. A nurse practitioner who was the acting physician for five residents told inspectors she had not been to the facility for eight months and that her office tried several times to schedule a time for her to make rounds there but no one returned her calls.
• The home failed to answer call lights in a timely fashion, with residents saying they waited 40 minutes to an hour for someone to respond. While inspectors watched, the call lights for three residents remained on at the nurses’ station more than 15 minutes as four nurses stood by. “None of the staff attempted to respond,” the inspectors reported. The next day, an inspector noticed that one resident’s call light had been on at the nurse’s station for 46 minutes. At the time, three nurse aides were standing at the nurses’ station talking, the inspector reported.
• The home was also cited for failing to follow professional standards of care for the administration of medication and treatment; failing to monitor a diabetic resident’s blood sugar, resulting in the resident being rushed by ambulance to a hospital; failing to provide complete and appropriate care for incontinent residents; failing to prevent and treat bed sores; failing to maintain residents’ nutritional status; failing to ensure that newly hired nurse aides were properly certified; failing to practice effective infection control; failing to maintain a clean kitchen while failing to serve food at a safe temperature; and failing to have sufficient, qualified nursing staff available at all times.