State Inspectors Cite Iowa Care Facility for Failing to Adequately Respond to Resident’s Head Injury

State inspectors have cited Dunlap Specialty Care for its poor response to a resident’s severe head injury, an injury that proved fatal.

This is one of the latest citations for a facility with a history of violations, including incidents of physical abuse and COVID-19 protocol breaches, raising serious questions about the oversight and management of this care facility.

On the morning of October 8, 2023, a female resident suffered a severe head injury after falling while attempting to walk to the bathroom without help. She was found on the ground lying in a significant amount of blood. However, no one told the resident’s hospice nurse until more than an hour and a half later.

The nurse got to the facility with the resident’s son more than an hour and a half after that. They observed lacerations on the resident’s arm, bruises on her head and a large hematoma around one of her eyes. The eye was also swollen shut.

The resident’s son allegedly told the staff that the nursing home should have transported his mother to the hospital as soon as they discovered she had fallen.

Unfortunately, it was not until approximately nine hours after the fall that a doctor ordered the resident undergo an evaluation at a hospital. Once there, she was diagnosed with subarachnoid hemorrhaging. Tragically, she passed away 24 hours later, with the hemorrhaging listed as the immediate cause of death.

As a result of this incident, the state proposed a fine of $11,500 against Dunlap Specialty Care, pending further evaluation by the Centers for Medicare and Medicaid Services (CMS). This action adds to a troubling pattern of sanctions against the facility, including a significant fine in June 2023 for resident abuse and safety failures. In 2022, Dunlap was assessed with a cumulative total of $200,489 in fines.

Dunlap Specialty Care’s history of problems is not limited to this tragic incident. The facility has faced multiple citations for its handling of the COVID-19 pandemic. For instance, their inadequate infection prevention measures, which may have contributed to a high number of resident deaths from the virus. Despite these issues, Dunlap Specialty Care has not received any greater level of scrutiny and assistance, despite being designated a special-focus facility designation by CMS. Additional oversight could potentially help this facility improve their standards of care, among other issues.

The facility’s parent company, Care Initiatives, has stated that the care and well-being of residents are their top priorities, emphasizing respect for residents’ rights and treatment choices. However, this incident and the facility’s history raise critical questions about the effectiveness of current oversight mechanisms. It also emphasizes the need for systemic changes to ensure the safety and well-being of nursing home residents.

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