Nursing facility fined $9,000 for infection and death • Iowa Capital Dispatch

A nursing facility in Iowa was fined $9,000 for failing to treat a pressure ulcer that contributed to a resident’s death.

State records show a woman was admitted to Elkader Care Center on Oct. 4 with a shallow, open wound on her buttocks. However, the care plan developed by the Elkader Home allegedly did not include measures to regularly reposition the woman to ensure the wound did not worsen, and staff allegedly failed to assess the wound.

On October 10, a nurse noticed that the wound had grown larger and was emitting an odor. The nurse later allegedly told state inspectors that she should have conducted a more comprehensive examination and informed the woman’s doctor, but she did not.

On Oct. 15, less than two weeks after being admitted to the Elkader Home, the woman was transported to a hospital emergency room after developing sepsis, a life-threatening infection. By this time the wound had deteriorated to the point where a nurse described it as “shocking” to inspectors.

On October 18, the resident died, with the cause attributed in part to sepsis related to the open wound. The resident’s GP reportedly told inspectors that the injury could have been avoided or minimized if staff had informed them of the woman’s condition.

State records show the Elkader facility has not yet paid 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 was cited for failing to provide residents with doctor-prescribed medications. In one case, the home had received a resident’s medication intended to slow the progression of his cancer, but the medication was not given to him for six weeks and it was not noted that the medication supply had not been depleted.

According to state inspectors, the resident subsequently showed signs of elevated proteins like those produced by cancer cells. Aside from the medication error, the home allegedly failed to notify the man’s family or doctor of the error as soon as it was discovered and did not conduct an internal investigation into how the error occurred.

The operations manager of the cancer center that treated the man allegedly told inspectors that the Clarion facility’s failure to provide the medication could accelerate the progression of the cancer and be fatal. The center’s registered nurse agreed and reportedly told inspectors the man had already undergone two stem cell transplants and she did not want to subject him to another stem cell transplant.

In another case of medication error, a Clarion House resident was mistakenly given her roommate’s six individual medications rather than her own. The error was only discovered when the resident who should have received the medication noticed that the choice of pills she had been given did not match her own. At this point, staff discovered that the two sets of medications had been accidentally mixed up.

The state proposed a $7,000 penalty and then suspended it so federal regulators could decide whether to impose their own penalty.

— Missed labs: The Des Moines Rehabilitation Center was sued after failing to properly complete blood tests ordered by a doctor for a resident who was subsequently hospitalized. Inspectors allege that in August, the resident’s doctor instructed rehabilitation center staff to check the resident’s sodium and potassium levels again within a week. The order was somehow missed and on August 27, the resident was rushed to the hospital and admitted with critically high sodium levels. The state has suspended a $5,200 fine.

– Abuse: The Rose Haven nursing home in Marengo, which was charged with failure to act, followed its own resident abuse policy after discovering that a resident’s narcotics were missing and may have been replaced with a similar tablet, acetaminophen. The home was fined $500.