Iowa DIA Fines Nursing Home Following Death of Veteran
The death of a resident of the Fonda Care Center in Pocahontas County resulted in a $6,500 fine assessed by the Iowa Department of Inspections and Appeals.
Marvin Jacobs, a U.S. Army veteran, died in February after his airway became clogged. He had a tracheostomy and sometimes his airway would get clogged. That is why a suctioning machine was kept next to his bed.
What Happened on February 19, 2023
Jacobs was sitting in his recliner in his room at Fonda Care Center on the afternoon of February 19 when he began struggling to breathe and pointed at his neck. The employee in Jacobs’ room told the aide to go get a nurse.
The aide went to go get the nurse and the employee who stayed in the room saw Jacobs become pale and continue to gasp for air. The employee then left the room and asked a nurse to use the suctioning machine.
The nurse went into the room and took Jacobs’ vital signs, saying Jacobs was having a heart attack. The aide told the nurse Jacobs had been trying to communicate that he could not breathe. The nurse asked for a minute and left the room.
Inspectors interviewed the nurse and she said she was told she would not need to do anything related to the tracheostomy. The nurse told inspectors she went to go get a blood pressure sleeve and other supplies to check Jacobs’ pulse and oxygen levels.
The nurse told staff at the time that she had to find out if the resident had a Do-Not-Resuscitate Order. While she was trying to figure this out, an aide told her to come to Jacobs’ room right away. When she went back in the room, she found Jacobs had no pulse, blood pressure or respiration. She pronounced him deceased.
The nurse told inspectors it did not occur to her to use the suctioning machine, even though her colleagues told her Jacobs could not breathe.
Regulators Fine the Facility and Facility Owners Respond
After investigating, the Iowa Department of Inspections and Appeals (DIA) fined the facility $10,000. They later reduced the fine to $6,500 because there was no appeal in the case.
The owners of Fonda Care Center, Care Initiatives of West Des Moines, wrote a response to regulators’ findings. The response says they are not admitting to any of the findings of state inspectors. They said they plan to continue providing care for patients with respiratory issues. This includes airway suctioning.
The DIA investigated 10 complaints against the facility while investigating Jacobs’ death. They also investigated two self-reported situations. However, just one of the complaints was substantiated.
In October of 2022, the facility was cited for 15 federal violations. Those violations included:
- Failure to apply comprehensive care plans
- Failure to remove accident hazards
- Failure to have enough nursing staff on site
- Failure to provide nutritious food
- Failure to use appropriate infection-control procedures
However, no fines were levied for these violations.
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