KEOSAUQUA — You won’t find the outcome online. The citation itself is tough to find. But the state says a Keosauqua nursing home did not challenge findings that it failed to adequately supervise residents.
The Good Samaritan Society Van Buren was fined $15,000 for a Class 1 violation and $500 for a Class 2 violation. The larger of the citations stems from a case in which a resident fell more than 50 times between Jan. 12, 2012, and her June 2013 death, the result of yet another fall.
The citation did not name the patient, but it indicates she could not safely walk unassisted and had problems with both her short-term and long-term memory. She was taken to the hospital on June 17, 2013, after a fall. She suffered a concussion and died four days later of bleeding between the brain and the skull.
Documents show the Class 1 violation was issued “as a result of multiple lesser violations … which taken as a whole constitute an imminent danger or a substantial probability of resultant death or physical harm to the residents of the facility.” The normal $5,000 fine was tripled as a result.
The citation report said family members had brought their concerns to the home. They acknowledged she would ignore instructions not to walk unassisted and was impulsive. But state investigators with the Iowa Department of Inspections and Appeals said the facility fell short of its responsibility to try to engage the resident and draw her into activities that would put a stop to her wandering.
Residents’ health was the focus of the Class 2 violation, which was issued after inspections showed residents did not receive adequate care after becoming incontinent, while others were not bathed regularly.
David Werning, a spokesman with the department, said Good Samaritan did not contest the findings. That allowed them to pay a discounted fine of $10,075.
“The facility is back in substantial compliance,” he said.