Iowa Authorities Cite Griswold Rehab and Health Care Center For Failing to Serve Prescribed Diets

Iowa authorities have cited a Cass County nursing home for failure to serve a prescribed diet. The citation follows the death of a resident after she was served coleslaw that had not been sufficiently minced.

Iowa’s Department of Inspections, Appeals and Licensing (DIAL) proposed fining the facility (Griswold Rehab and Health Care Center) $10,000. However, this fine is being suspended to allow federal officials to determine if federal penalties should be imposed, reports the Iowa Capital Dispatch.

Resident Struggled to Breathe for 21 Hours

The female resident passed away at the hospital on August 31, 2023, of respiratory failure. X-ray images revealed she aspirated on an unidentified organism.

DIAL says the resident was prescribed a certain diet because of her problems with swallowing. Three days before she passed away, she was served coleslaw. However, the coleslaw was not properly minced.

Later that evening, nursing home staff members saw the resident coughing. The resident’s lungs were gurgling, and oxygen saturation levels were measured at 70 percent. Anything less than 80 percent means the person needs immediate medical attention.

A little less than one day later (21 hours), an aide found the resident having difficulty breathing. She was also coughing and coleslaw came out of her nose.

The aide was interviewed by Iowa DIAL inspectors and she said she told the director of nursing about the resident. However, the director decided not to evaluate the resident or check vital signs.

The aide then talked to a registered nurse who gave the resident oxygen, called a doctor and had the resident sent to the hospital. The hospital admitted the resident for aspiration pneumonia.

Lack of Staff May Have Led to Resident Receiving Coleslaw

DIAL inspectors talked to the dietary manager at Griswold Rehab and Health Care Center. She said the resident should not have been served coleslaw. However, the dietary manager said the facility was short-staffed. She had to serve meals with one high school student who was there to help. The manager said a nurse or aide probably picked up the wrong plate by mistake.

Past Citations Imposed on Griswold Rehab and Health Care Center

This Iowa nursing home received another citation for failing to sufficiently protect residents from abuse. This came after a resident reported hearing a sound that he thought was his roommate falling. The noise was preceded by a staff member telling the resident’s roommate to get dressed about 50 times.

The resident’s roommate received medical treatment for injuries to a finger, elbow and knee. Later, the roommate pointed at an aide and said she was the one who caused the injuries. However, the aide denied wrongdoing.

Griswold Rehab was cited for 10 other violations of regulations. In the summer of 2022, the facility also received a citation for not recognizing abuse and failure to protect residents from abuse. This resulted in a federal fine of $28,103.

This nursing home has a one-star rating from the Centers for Medicare and Medicaid Services for overall quality and inspections. One star is the lowest rating a nursing home can get.

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