The Ottumwa Courier

August 29, 2013

Nursing home cited in patient's fall, death

Courier staff writer

---- — KEOSAUQUA — A Keosauqua nursing home face more than $15,000 in fines after the Iowa Department of Inspections and Appeals found it failed to adequately care for residents, including one who fell more than 50 times since January 2012.

The fines are shown in a citation that details events that led to a patient's death in June. The patient, whose name is not given in the citation, had both short- and long-term memory problems and could not safely walk unassisted.

Some nursing homes use a fall risk analysis in which a score of 12 or above indicates a high risk for falls. In December 2012, the resident scored 19. By April of this year, the same analysis gave the resident a score of 25.

From Jan. 12, 2012, to Dec. 19, 2012, records showed the resident fell 36 times, mostly in the afternoon and evening hours. Another 19 falls in 2013 are indicated in the report. Investigators concluded the facility attempted to address environmental issues related to the falls “but did not look at engaging the resident in activities to avoid the wandering behaviors.”

Family members had concerns. They acknowledged the resident would ignore instructions not to walk unassisted and “impulsiveness.” But investigators said the family told them repeated discussions with the nursing home failed to ensure they helped the patient walk or intervene when they discovered the resident doing so.

On June 17, the resident fell in the hallway and was unresponsive when staff got there. There were signs of a concussion, and the resident was taken to the hospital by ambulance. On June 21, the resident died of a subdural hematoma, bleeding between the brain and the skull, caused by the fall.

Staffing appears to be part of the issue, according to the investigators' report. According to a nursing assistant on duty the when patient fell, there were “not enough staff on the evening shift to care for all the residents” and provide the resident who fell with walking assistance.

Another nurse said a typical evening shift included one nurse and one certified nurse's aide. Review of the records showed there were approximately 17 residents for whom those two people would be responsible. Day shifts usually had two or three CNAs available.

The facility's director of nursing said she did not have staff to provide individualized care for the resident.

The death of a resident wasn't the only thing investigators took issue with. The report indicates two residents received inadequate care after episodes of incontinence, six failed to be bathed at least twice weekly, and three did not receive proper oral care. Fines for those cases total $500.

Investigators were told the facility had a shower aide who was responsible for bathing residents but that floor nurses pulled the aide off shower duty to help when they were shorthanded.

The report does not include a formal response. The facility has up to 30 days to request a formal hearing to contest the citation.