Nursing Home Cited in Resident’s Death Fined Again in New Incident
Jeffrey A. Pitman · October 30, 2024
Jeffrey A. Pitman
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On February 11 a female resident was found dead in an Iowa nursing home. She was face down on the bed, with her head trapped between the mattress and bed rails. The facility where this happened, Muscatine’s Lutheran Living Senior Campus, was cited in this incident for failing to protect residents against hazards. This facility is now being cited for new violations.
Why Lutheran Living Was Cited in February
The incident that occurred on February 11 at about 4:30 a.m. was poorly handled. A Certified Nursing Assistant (CNA) at Lutheran Living reportedly heard a woman calling out for someone to help her. Despite the distress in the woman’s voice, however, the CNA reportedly believed the female resident was fine and continued doing rounds instead of checking on her.
A news article reports that not long after that, another CNA found the woman half out of bed and unresponsive. That CNA sought help from a nurse, but instead of providing assistance, the nurse said the woman was not her responsibility. She instructed the CNA to notify the CNA on-shift for that hall.
The two CNAs say they returned to check on on the woman a few minutes later, but by that time, she was unresponsive and face down on the bed. Her head was stuck between the mattress and the bed rails.
New Citations Against Lutheran Living
On October 10, the state assessed new citations against Lutheran Living for an incident that occurred in August. In this incident, a resident with dementia was able to escape the facility unnoticed in his wheelchair. The resident made his way to a grassy part of the facility property before tipping over and falling onto the grass. A visitor who saw what happened alerted staff.
Initially, the state proposed a $6,750 fine for failing to protect residents from harm. Since it is a repeat violation, however, that fine was increased to $20,250. This amount has been held in suspension to give the federal government time to consider enforcing a fine of its own.
Staffing and Negligence Issues
The earlier investigation revealed that the nursing home was severely understaffed on the night of the resident’s death. Two of the on-call CNAs left their shifts early. The remaining staff say they sought assistance from the assistant director of nursing. According to them, their pleas were ignored. However, the assistant director of nursing reportedly told inspectors she never received that call or any request from the CNAs.
Inspectors later reviewed the assistant director of nursing’s personnel file. They discovered she had been reprimanded for failing to come to work and failing to fulfill her responsibilities the night the woman died.
Lutheran Living has an overall rating of one-star on the five-star rating scale implemented by the Centers for Medicare and Medicaid.
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This page has been written, edited, and reviewed by a team of legal writers following our comprehensive editorial guidelines. This page was approved by attorney Jeffery A. Pitman, who has more than 28 years of legal experience and handled thousands of personal injury cases while obtaining millions of dollars in verdicts and settlements in Wisconsin.
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