Hospitals cited for abuse, dirty ORs and forcing a homeless vet onto the street

Over the past 12 months, Iowa hospitals have been cited for dozens of violations, including a dirty surgical suite, patient abuse, inadequate staff, and discharging emergency-room patients with undiagnosed, life-threatening conditions.

In one instance, according to state records, an eastern Iowa hospital discharged a homeless, wheelchair-using veteran to the street, although the man had no phone, no destination and no transportation. Later that night, motorists spotted the man trying to merge into interstate traffic in his wheelchair.

Another Iowa hospital was cited for a situation in which an intruder made his way into a neonatal intensive care unit, where he changed a baby’s diaper and fed the baby before being fleeing on foot when confronted by the staff.

Although most Iowa hospitals are inspected only by private accrediting organizations, some are inspected by the state as result of complaints or allegations that patients have been discharged from emergency rooms without first being stabilized.

Here’s a look at the violations cited by state inspectors at Iowa hospitals during the past 12 months:

Trinity Hospital, Bettendorf – In August, Trinity was cited by the state for discharging a patient without first ensuring they were stable. According to inspectors, an 81-year-old man came to the hospital’s emergency room by ambulance on June 16, complaining of chronic back and shoulder pain and seeking nursing home placement due to being homeless, wheelchair using and unable to meet his own needs.

An advanced registered nurse practitioner performed a physical exam, ordered laboratory tests and sought a case-management consultation. A physical therapy evaluation was also conducted, but the results were not reviewed by the nurse practitioner. A social worker was unable to find a nursing home placement before leaving work at 5 p.m., but asked a nurse to give the man phone numbers for the Veterans Administration and for a state program called Iowa Total Cares.

Six hours after arriving at the hospital, according to inspectors, the man was discharged “to the streets.”

The nurse practitioner wrote in the medical file: “Patient was told multiple times that he was to exit the ER as he was discharged. Patient was … (told) that the nursing home would not accept him … and the homeless shelter refused to take him back … Patient was asked to pack up and vacate the ER. Patient was given a glass of coffee for the road and papers to be discharged.”

In their report, inspectors noted that Trinity had discharged “a homeless 81-year-old wheelchair-bound patient without any means of transportation to a homeless shelter which was located miles from the Emergency Department, to the streets on a hot afternoon.”

Several hours after leaving Trinity, close to midnight, the man was picked up by emergency medical personnel near Interstate 74 where members of the public had seen a man in a wheelchair attempting to merge with traffic onto the interstate. He was taken to a different hospital, where he was diagnosed with dehydration and admitted for further observation.

The nurse practitioner at Trinity later told inspectors, “I didn’t have an admitting diagnosis, I didn’t have any criteria to keep him.” She acknowledged she had not read the physical therapy evaluation that indicated the man was unsafe to be left alone and was at a high risk for falls, although she had signed the report. The nurse practitioner also told inspectors there were many shelters for the homeless in the area, although she didn’t know where they might be located. She said it was very “upsetting” when she later learned the man had no transportation and no destination when he was discharged from Trinity.

Another nurse at Trinity told inspectors she didn’t question the nurse practitioner’s decision although she knew the man had nowhere to go, no phone and no transportation. “The way I look at it,” the nurse reportedly told inspectors, “I just follow what my (employer) tells me to do.”

Clive Behavioral Health Hospital, Clive – In July, state inspectors visited this hospital in response to six complaints over the previous two weeks. The hospital was cited for an incident in which a patient required emergency-room evaluation after disassembling a toilet lid and ingesting several bolts. The hospital fixed that patient’s toilet but didn’t fix any of the 70 other toilets that created the same potential for harm.

In April 2022, inspectors cited the hospital for nine separate regulatory violations. During that inspection, state officials determined the hospital’s patients had been put in “immediate jeopardy” and that there was a “crisis situation that placed the health and safety of all patients who received care at the hospital at risk for harm or death.”

That finding was tied to an incident in which a patient attempted suicide by wrapping a cord from their jacket around their neck. The hospital staff allegedly failed to take action after the incident to prevent other patients from bringing items into the locked psychiatric ward so they could use them as a ligature device to attempt suicide.

In addition, inspectors cited the hospital for admitting two individuals without assigning them a bed. That resulted in the two patients sleeping on mattresses placed on the floor in common areas where others could congregate. Further reviews of hospital records uncovered 18 other incidents in which patients were admitted with no beds available, which resulted in patients being assigned to common areas rather than patient rooms. The chief medical officer explained the rationale for the policy was to begin delivering needed treatment to the patients even if no rooms were available.

The hospital was also cited for an incident in which a patient swallowed a marker, necessitating surgery because the object could have ruptured the patient’s internal organs and caused death. A mental health technician told inspectors the hospital sometimes lacked adequate staffing to provide the necessary one-on-one observation of residents in need of constant supervision.

The hospital was also cited for failing to test new patients for COVID-19 prior to their admission. The chief medical officer told inspectors the hospital had been relying on a questionnaire to screen psychiatric patients for COVID-19, and unless the new patients showed signs of COVID-19, they were not tested. The practice was in violation of the hospital’s own policies.

In late 2021, the hospital was cited for 12 regulatory violations and was deemed to have placed patients in immediate jeopardy. During that inspection, it was discovered that the staff had left a pediatric patient alone in one unit of the hospital, with no staff members on the floor to provide supervision. The hospital’s chief financial officer wrote up a report of the incident and submitted it to a manager. The manager later told inspectors that pursuant to instructions from the hospital’s corporate compliance officer, the report was then shredded.

In addition, inspectors reviewed video of an incident in which a patient was physically dragged from their room by their limbs, down a hallway and into a seclusion room. Another patient was carried by their limbs into their room. The hospital’s intake coordinator later acknowledged that patients should not be carried or dragged by their limbs due to the potential for additional injury. The hospital’s CEO acknowledged a child-abuse investigation had not been completed after the incidents and indicated the hospital was unaware of whether the potential abuse had been reported to the state as required.

The hospital was also cited for routinely failing to ensure the emergency department and intake unit were staffed with a registered nurse at all times to assess new admissions and address any urgent issues that may arise. In addition, inspectors reviewed staffing records for 22 days and determined that on 14 of those days, the hospital failed to have adequate nursing supervision, with only mental health technicians working some units for up to 12 hours at a time. In addition, one patient was given psychiatric medications without a physician’s order.

The November 2021 inspection followed an August 2021 inspection in which the hospital was cited for 19 regulatory violations. At that time, inspectors found that one child’s guardian had complained to the nursing manager about child patients engaging in sexual activity with other child patients. The patients had developed a system of knocking on walls to alert each other to the presence of staff.

The guardian complained that the hospital “is supposed to be a safe setting.” The nurse manager relayed the concerns to the chief nursing officer who then “forgot about” the complaint, according to inspectors. A nurse later reviewed a video recording showing child or adolescent patients engaging in sexual activity while left unattended in the hospital’s “nourishment room.” An incident report was completed two weeks later, but no investigation was conducted.

The CEO later acknowledged that the hospital’s board of governors was not given information on incident reports filled out by the staff. One child’s journal was found to have included descriptions of sexual activity that had taken place among four pediatric patients. The incidents allegedly occurred in the nourishment room, playground and under a table in the child-and-adolescent unit.

Eagle Behavioral Health, Bettendorf – In May of this year, inspectors cited the hospital for a “patient rights” violation tied to alleged physical abuse. A child had complained to the hospital’s patient advocate about a staffer who was “very mean” and had dragged them from a room by their legs. Hospital administrators then reviewed video of the incident and produced a report that said the worker had grabbed the patient’s ankles, pulled their pants off, and then placed the patient’s arms behind their back and “aggressively” tossed the patient into a room where their head slammed into a wall and they fell to the floor.

The incident was not reported to regulators as abuse, the hospital said, because the director of quality, risk and compliance had concluded it did not fit the hospital’s definition of abuse.

In February, the hospital was cited for discharging a patient to a group home without the expected advance notice, without the promised 30-day supply of medications, and without any of the necessary paperwork to assure a smooth and safe transition. The hospital’s discharge-planning staff and nursing staff blamed each other for the situation. A representative of the group home told inspectors similar problems had occurred with Eagle Behavioral Health in the past.

Mercy Hospital, Iowa City – In April 2022, the hospital was cited for failing to report two incidents of potential dependent adult abuse. The situation involved a nurse who was believed to have misappropriated fentanyl on two occasions by obtaining it for patients who had no order in place for the drug. The hospital was also cited for failing to have conducted an adequate background check on the nurse in question.

MercyOne-Des Moines Medical Center, Des Moines – In June 2022, the hospital was cited for destroying a portion of a patient’s medical record. The written, hard-copy document reflected the observed behavior of a patient in the emergency department and was accidentally destroyed without being scanned into the patient’s electronic medical file.

In February, the hospital was cited for four regulatory violations. One of the violations was related an unidentified man who gained access to the hospital’s neonatal intensive care unit at 11:19 p.m. on Dec. 27 , 2021. The man fed a baby and changed the baby’s diaper before being caught and removed from the unit.

An investigation showed the man had entered the unit while a nurse exited through the same doors. He then entered a patient room and, after telling a nurse he was the baby’s father, he donned a gown and gloves and changed the baby and began feeding it. The nurse, who later reported she felt “uncomfortable,” asked the charge nurse to report to the room. It was then determined that the baby’s actual father was in a separate area of the hospital and the intruder was asked to leave.

The man then “took off down the stairs,” inspectors reported, and the staff were alerted to the incident. The intruder was later arrested and ordered to pay $736 in fines after being convicted of trespassing.

Weeks later, inspectors reported, a root cause analysis of the incident had yet to be completed by the hospital, and the staff was not monitoring the corrective actions they had put in place in the immediate aftermath of the incident. Also, the staff failed to properly screen the hospital inspector who entered the facility to investigate the matter, and, on one occasion, didn’t ask for the inspector’s ID.

MercyOne-Newton Medical Center, Newton – In March 2022, the hospital was cited for failing to ensure the staff properly cleaned the operating room suite and for failing to ensure the surgical staff followed infection-control procedures.

Inspectors who observed the cleaning process used in preparation for the next operation noted that the staffer charged with cleaning the operating room failed to clean the walls; failed to clean the floor underneath an anesthesia cart; wiped the floor too quickly after spraying it with a cleaning solution; and walked on the freshly mopped floor with uncovered shoes and soiled, tattered pants that dragged across the floor.

The same worker was also seen wiping the outside of a trash bin for biohazardous materials and then using the same rag to wipe the stainless-steel tray that holds scalpels and other instruments used in surgical procedures. The worker then placed clean operating-room linens against their chest before placing the linens on the operating table. According to inspectors, the hospital was performing an average of 267 surgical procedures per month.

The hospital was also cited for failing to develop and implement an adequate quality improvement program to ensure that patient care was assessed in nine separate departments, including surgery, speech therapy, occupational therapy, ultrasound, MRI and the wound clinic. In addition, it was also cited for failing to keep patients’ medical records in a secure area, with the inspector noting several bins filled with patient files were left sitting on the floor in an area where the housekeeping staff and others had access. In addition, the hospital was cited for failing to ensure pharmacy oversight and tracking of sample medications.

MercyOne-Siouxland Medical Center, Sioux City – In May 2022, the hospital was cited for failing to develop and implement a system to determine whether all members the medical staff had been vaccinated against COVID-19. The hospital had asked members of the medical staff to sign a document attesting to the fact that they had either completed their COVID- 19 vaccinations or had obtained an approved exemption. The hospital’s vice president of quality and integration acknowledged that this meant it was impossible say whether the 142 licensed professionals who signed the document had actually received a COVID-19 vaccination.

MercyOne-Waterloo Medical Center, Waterloo – In April 2022, the hospital was cited for failing to ensure patients received care in a safe environment. In reviewing three patient files, inspectors concluded that in all three cases, the emergency department documented unstable behavioral health issues but failed to provide adequate supervision to prevent any attempts by the patients to harm themselves or others.

On April 9, two patients came to the hospital independently of each other, with each of them saying they wanted to kill themselves. Both were to be checked every 15 minutes, but the task was delegated by a nurse to a security guard. The guard was called away at one point, so the task reverted to the nursing staff, who failed to perform the checks for more than three hours. A nurse told inspectors that due to a shortage of staff the ER could not provide the required monitoring for suicidal patients. However, the inspector reviewed video footage that allegedly showed the nursing staff “randomly” walking around the department and attending to various tasks without ever checking on the two patients or looking at the video-monitor screens.

In December 2021, the hospital was cited for its response to allegations of abuse. Inspectors reviewed the personnel file of a former security guard and found notations indicating that on Sept. 9, 2021, a staffer had alleged the security worker “applied closed-fist strikes to a patient.” A month later, the file indicated, the security worker was involved in an incident with a different patient and had “applied seven closed-fist strikes to the patient’s head.”

The security worker was fired at that point, but the hospital failed to conduct a thorough investigation of the incidents, inspectors said. Also, inspectors said, the hospital failed to do an adequate background check on the security worker before he was hired.

Methodist Jennie Edmundson Hospital, Council Bluffs – In April 2022, the hospital was cited for failing to adequately assess a patient who came to the emergency room via ambulance with an elevated blood pressure, elevated heart rate and severe abdominal pain. Three hours later, the pain had not subsided, was getting worse and the patient’s heart rate was still elevated. At one point, the patient fell to the floor and struck their head. The patient was discharged to their home with no painkillers and no evidence in the medical record that anyone had tried to “identify the underlying cause” of the symptoms, inspectors reported. Within a half-hour of arriving home, the patient went to a different hospital and was admitted for further care.

St. Anthony Regional Hospital, Carroll – In March 2022, the hospital was cited for 11 regulatory violations. Inspectors alleged the hospital failed to follow its own guidelines for addressing patients’ grievances and had failed to send 32 patients a follow-up letter in response to grievances they each had filed between January 2021 and February 2022.

In addition, the hospital was cited for placing a suicidal patient in restraints for 12 hours without the required physician’s authorization; failure to perform preventive maintenance on equipment; storing outdated medications; and keeping a large number of medical records in a non-secure location. A tour of the surgical department and ER also revealed a large number of outdated supplies, including iodine preparation pads that had expired in 2019; a cotton-tipped applicator that expired in 2014; surgical lubricants that had expired the previous September; and insulin syringes that had expired nine months earlier.

Trinity Regional Medical Center, Fort Dodge – In March 2022, the hospital was cited for discharging a patient who had not been stabilized, forcing the patient to travel 25 miles to another hospital where they were diagnosed with a life-threatening infection. The patient had come to Trinity on Nov. 7, 2021, via ambulance, from a nursing home. The patient was complaining of severe pain that rated 10 on a scale of 1 to 10. The emergency room physician wrote in the patient’s file: “I do not feel there is ever a way that (the patient) is going to be out of pain. I think (the patient’s) expectations of pain control are way out of proportion.”

The patient was discharged back to the nursing home. The medical record lacked any evidence the patient’s pain was reassessed after a muscle relaxant was provided, inspectors said. There was also no indication the hospital assessed an open pressure sore on the resident’s back despite its presence being noted in the medical record.

The patient returned four days later, again complaining of severe pain. Tests were ordered and medication was given, and four hours later the resident was discharged. Hours later, the patient was taken to different hospital where they were diagnosed with an infection and a severe pressure sore than was deep enough to reveal exposed bone.

UnityPoint Health-Des Moines Methodist Medical Center, Des Moines – In February, the hospital was cited for allowing a nurse to continue working for 12 hours after it suspected she had diverted patient painkillers to her own use. The hospital also failed to report the matter to the state as a case of suspected dependent adult abuse.

Unity Point Health-Marshalltown, Marshalltown – In March, the hospital was cited for six regulatory violations, including failure to ensure pharmacy oversight of sample medications; failure to notify physicians about medication errors in nine of 17 cases; and failure to change an irrigation bottle between uses, creating a risk of infection in patients.

University of Iowa Hospital & Clinics, Iowa City – In March, the hospital was cited for placing patients in immediate jeopardy due to a failure to separate patients from a psychiatric nursing assistant who was suspected of abuse. The situation involved a staff member who alleged saw the nursing assistant physically strike a combative patient in the shower.

The incident took place in November 2021 and was reported to the nurse manager who didn’t take steps to isolate the nursing assistant from other dependent adults in the geriatric unit. The nursing assistant continued to see patients into May of this year, even after the state inspections department notified the hospital it would be investigating the matter.