Iowa Nursing Home Cited for Gangrene and Death of Resident
A nursing home in Iowa received multiple citations this past March for several state and federal regulatory violations. Following 23 individual complaints for the same facility, inspectors investigated the facility. Out of the exceptionally high number of complaints received, inspectors were able to substantiate 19.
What You Should Know About This Facility
The facility, located in West Des Moines, was operating under the name of Promedica Skilled Nursing and Rehabilitation Center at the time of the investigation. However, this nursing home has also operated under other names. Before 2021, the facility was called ManorCare Health Services of West Des Moines. Since early April, this facility began operating under yet another new name. The facility is now operating under the name, Harmony West Des Moines.
A Resident Became Septic and Died
A news article reports that when a family member visited Harmony West Des Moines on February 13, her loved one said she was feeling extreme pain in her buttocks According to the relative, no one came to check in on her loved one in the four hours she was visiting. Her family member continued to suffer and cry in pain, but no one gave her any medication to help relieve it.
One nurse told inspectors that the woman had a fissure, which she reported to an on-duty advanced nurse practitioner (ARNP). Some ointment was ordered, but there was still no physical assessment of the woman’s condition. The woman continued in this condition for over a week without a medical examination.
On February 25, one of the nurses reported there was bright red fluid coming from the woman’s buttocks. These findings were also reported to the facility’s nursing director. Although a physician was called and treated her for constipation, there was still no medical assessment done.
On February 27, the woman was found with bowel excrement flowing from her vagina and still yelling in pain. A doctor finally gave the order to send her to the ER, but by the time she got there, she was already in septic shock. The woman was operated on the next day, but died only days after her surgery.
Resident Who Contracted Gangrene
The daughter of another female resident at Harmony said she was called around 2 a.m. from her mother’s roommate at the facility. She was told then that her mother was screaming with pain but getting no help from staff.
When she visited her mother later that same day, the daughter said her mother’s arm was hurting so badly that she could not even touch it.
The daughter used her own phone to call her mother’s doctor. Once she got hold of the doctor, she tried to give the phone to the male nurse on call. However, he refused to speak to the doctor. In fact, according to the daughter, the male nurse said he did not have time to give her mother her pain medication. Her mother still had not been given any medication three hours later.
Later that night, the roommate called again. This time, the daughter said she could her mother screaming in pain over the phone. When another daughter of the resident went to visit her mother at the facility, she found she had been transported elsewhere, but staff at the facility would not tell her where.
Mercy West Hospital eventually called the sisters, telling them their mother needed emergency surgery because her right arm was turning black and she had no pulse in her right arm. Staff indicated an amputation might be necessary.
Over 20 Violations
These and other incidents led the Iowa Department of Inspections and Appeals to cite Harmony with 20 regulatory violations, including failures for not maintaining sufficient staff, inadequate infection care, not managing patient pain, and overall, not meeting quality of care standards.
Fines were also assessed against the facility, totaling $19,000. These are not the first fines assessed against the Iowa nursing home. CMS previously fined the facility $30,000 in 2021. However, those fines were reduced by 35 percent because the facility did not appeal the case. In 2022, CMS again cited and fined the nursing home, this time for $15,000. Since the nursing home also did not appeal that case, that penalty was reduced to $9,750.
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