Pella Chronicle

October 30, 2012

Recently fined nursing home has history of violations

By Kyle Ocker, Daily Iowegian
Daily Iowegian

CENTERVILLE — Golden Age Skilled Nursing and Rehab, the nursing home recently fined $8,000 by the state for failing to help a dying woman, has a long history of citations and violations.

According to records made available from the Iowa Department of Inspections and Appeals website and compiled by the Daily Iowegian, the Golden Age has received $56,675.50 in fines and 123 violations since Dec. 3, 1999, the date of the first record available online.

The Daily Iowegian compiled similar numbers from facilities with the same classification as Golden Age in Appanoose, Davis, Monroe and Wayne counties.

A total of seven active facilities were studied via online records, which covered a timeline between June 1999 and June 2000 through today.

The seven nursing homes combined for $141,150.50 in fines, 548 violations and 52 citations. Golden Age accounts for roughly 40 percent of the fines, 22 percent of violations and 23 percent of citations.

So far this year, Golden Age has received $15,000 in citations and inspections have uncovered 27 violations.

A Sept. 11 report penalized the nursing home for failing to “provide an accurate assessment and timely intervention” when a resident, who The Des Moines Register reports was 64 year old Barbara Logsdon, had problems clearing her throat of phlegm that had built up and eventually died, despite a physician ordering regular suctioning of Logsdon’s throat due to a medical condition .

The nursing home was fined $8,000 for violating four regulations.

A 106-page report filed approximately two weeks prior to Logsdon’s death fined Golden Age a combined $7,000 for 23 violations.

The report noted Golden Age’s many violations, ranging from failure to notify a physician of a resident’s hour-long grand mal seizure to failure to meet professional standards.

A report from July 23, 2010, fined Golden Age a total of $20,000, when “the facility failed to plan nursing services with provision of assessments and timely interventions for one of three residents reviewed.”

The fine would have been $10,000, but it was doubled to $20,000 under section code 56.6(2), which states “the director of the department of inspections and appeals shall double the penalties specified in subrule 56.3(1) when the violation is due to an intentional act by the facility in violation of a provision of Iowa Code chapter 135C or rule adopted pursuant thereto.”

A resident who had surgery for spinal fusion of the lower back on Feb. 24, 2010 entered Golden Age on May 21, 2010, without any compromised skin areas on the left heel, right elbow and middle left toe. The report states that the facility had no assessment or intervention in place to address the pressure areas from the onset to May 21, 2010 and did not accurately assess the resident’s coccyx ulcers.

The report continues to state that the resident began having complaints of shortness of breath and was sent to the emergency room by the nursing home.

Upon admittance to the ER on May 21, 2010, an ER nurse told surveyors “she took photographs and attended to [the resident] upon admission… The ER nurse stated she removed the resident’s socks after she noticed a foul odor on the resident. The ER nurse stated she noticed a small scab [black area] on the resident’s toe with soft, red mushy skin on the right heel. The ER nurse asked the resident if s(he) move[s] around a lot and the resident stated ‘no.’  The ER nurse stated she rolled the resident to his/her side due to him/her complaining of his/her bottom being sore. The ER nurse stated she observed a large excoriated area with necrotic and red open sores on the coccyx/buttocks. The ER nurse stated she smelled a foul odor and noticed yellow drainage with dry fecal matter. The ER nurse stated the resident’s loved one was present at the bedside and stated the resident had been living at the nursing home for the last couple of months.”

According to the report, the ulcer found on the resident after the ER nurse removed the sock was approximately the size of a 50-cent piece.

An interview with the resident’s physician uncovered that the physician had no knowledge of open areas on the resident other than the coccyx, and also that no staff at Golden Age had notified him of an open area on the resident’s right elbow, left heel or left middle toe.

A surgeon that on duty when the resident was admitted said, according to the report, “it would take 2-3 weeks, most likely a month for the area on the resident’s heel to develop. The surgeon stated it would be hard to deny the area was present much of the time the resident was in the care center since the resident [was] admitted to the facility on [March 11, 2010] and admitted to the hospital on [May 21, 2010].”

During interviews, one staff member said she did not see the resident’s heels being open, but did notice the area on the middle toe and failed to report it to a nurse.

Golden Age received a total fine of $7,500 in April 2010 for several violations.

A $6,000 fine was assessed because the facility failed to ensure residents received safety provisions, a resident was able to elope when staff failed to respond to an alarmed door, a resident suffered a left clavicle fracture when straps on a lift broke during a transfer, a resident was not properly supervised from potential hazards in the environment and failing to provide safe transfer for three residents.

In the same report, Golden Age was fined $500 for not alerting the Director of Nurses of the elopement of the resident. Another $500 fine was assessed when Golden Age failed to obtain a state required abuse background, to check for past abuse on children and dependent adult records, before an employee is hired to work at a facility such as Golden Age.

Other large fines assessed to Golden Age include a May 2007 fine of $2,500 and a $2,540 fine in March 2007.