Judge: Nursing home resident died after worker ignored orders

A Des Moines nursing home employee who allegedly contributed to the death of a resident has been denied unemployment benefits.

State records indicate that in December 2020, Richard A. Kerr began working as a cook for Des Moines’ Trinity Center at Luther Park nursing home. He remained employed there until he was fired in July 2022.

According to records tied to his subsequent request for unemployment benefits, Kerr was responsible for preparing meals for all of the residents according to the individualized menus created by his supervisor, Kris Gilman, the facility’s culinary director.

Because some of the residents were on restricted diets that required soft or pureed food, Gilman crafted the menus to conform to physicians’ orders.

In February, Gilman allegedly learned that Kerr was changing the menus for some of the residents, which required Gilman to change them back so they would conform to the physicians’ orders.

At the time, Gilman allegedly reminded Kerr that she was the only person authorized to specify the food items to be prepared and served to residents, and she noted the potentially fatal risks associated with giving residents food that posed a choking hazard.

On July 15, Trinity Center’s skilled-nursing facility admitted two new residents. According to the findings of the judge who presided over a hearing on Kerr’s request for jobless benefits, Kerr contacted Gilman and asked her whether she wanted him to devise menus for the two individuals. Gilman allegedly said that she would do it.

Kerr opted to create the menus anyway and entered “meal tickets” for the two residents into the system, according to the judge’s findings. In the process, he incorrectly indicated one of the residents could have a regular or unrestricted diet, although that resident’s medical orders limited their diet to soft, bite-sized pieces of food.

As a result of the alleged error, the resident was given pulled meat instead of ground meat. The resident choked on the meat, was taken to a hospital and died. Kerr was fired several days later.

He was initially awarded unemployment benefits, but Administrative Law Judge Carly Smith recently reversed that decision on appeal and denied Kerr benefits.

In her ruling, Smith noted that Kerr had been “made aware that it was dangerous for him to enter the meal tickets when he was not properly trained because it could have a harmful impact on residents, i.e. choking.” She wrote that “as a result of (Kerr’s) failure to follow directions, a resident choked on the food, was hospitalized and died.”

State records indicate Trinity Center at Luther Park has been inspected at least twice by the state since the July death, but no fines or citations were issued after either visit. The published reports make no reference to a resident dying as a result of a staff error that led to choking.