Nursing home worker says she was told ‘keep your mouth shut’ about man’s death

An alleged whistleblower who says she was fired from a nursing home after being instructed to “keep your mouth shut” about a resident’s death is suing her former employer.

Tylene Schultz is suing the Fonda Specialty Care nursing home, its parent company, Care Initiatives, and licensed practical nurse Becky Manning in Pocahontas County District Court.

In her lawsuit, Schultz claims that in the summer of 2022, she was hired at Fonda Specialty Care by its then-administrator, Jennifer Blair, to work in the home as a certified nursing assistant.

On Feb. 18, 2023, the home allegedly scheduled a temp-agency nurse, Manning, to work the overnight shift due to a shortage of staff nurses. During the shift, a resident with a tracheostomy passed away about 2:25 a.m., the lawsuit claims.

State records indicate the resident who died was 87-year-old Marvin “Pete” Jacobs, who had undergone a tracheostomy and needed regular suctioning of his airway. The lawsuit claims Jacobs died because throughout the shift, Manning refused to numerous requests to suction Jacobs’ airway.

“Despite multiple requests by Schultz to suction the resident — over 10 times, from 6 p.m. on Feb.18, 2023, to 2:25 a.m., Feb.19, 2023 — Manning would not suction the resident, nor did she attempt to use the suction machine,” the lawsuit claims.

Schultz alleges she tried to call “supervisory level staff” who worked for the home, but none of the individuals answered the calls. She also alleges she asked that someone call 911, but Manning told her no physician was available at that hour to provide an order for a hospital evaluation.

An ‘agonizing and painful’ death alleged 

In her lawsuit, Schultz alleges she and another CNA remained with Jacobs as he “pointed to his neck, coughed, gagged, struggled to breathe, and turned colors from the lack of oxygen, until he finally passed away. From Schultz’s direct observation of the resident, his death was agonizing and painful.”

Schultz alleges she and a fellow CNA were so traumatized by the death they had to excuse themselves from the facility and were standing outside the building in an “emotionally hysterical” state. The other CNA was “physically ill, to the point of vomiting,” when an ambulance crew arrived to confirm Jacobs’ death.

According to the lawsuit, after Schultz left the home at the end of her shift, she received multiple text messages from Blair that said, “Keep your mouth shut and keep your opinions to yourself,” along with instructions that she should not communicate with Jacobs’ family.

Later that day, Schultz was summoned to a meeting with Blair at Fonda Specialty Care. During the meeting, the lawsuit claims, Blair — who was allegedly was aware Schultz planned to call state regulators and report her concerns with Jacobs’ care — informed Schultz she was being fired due to “resident complaints.”

The lawsuit claims Blair also stated that Schultz had violated patient privacy provisions of the federal Health Insurance Portability and Accountability Act by calling a co-worker at home and asking for their assistance with Jacobs’ situation.

Schultz alleges she reported her concerns with Manning’s “actions and inactions” to both the Iowa Long-Term Care Ombudsman’s Office and the Iowa Department of Inspections, Appeals and Licensing.

DIAL subsequently cited Fonda Specialty Care for “failing to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care,” and fined the home $10,000. The penalty was then reduced 35%, to $6,500, due to the lack of an appeal in the case.

Manning was criminally charged with felony wanton neglect of a resident of a health care facility and later pleaded guilty to misdemeanor wanton neglect. Last year, Manning entered into an agreement with the Iowa Board of Nursing in which she agreed to indefinitely suspend her practice of nursing.

In her lawsuit, Schultz alleges she was “fired for making a complaint to the ombudsman and the Iowa Department of Inspection of Appeals due to the suspected abuse and/or neglect of the resident … and not based on any resident complaints.”

The lawsuit seeks unspecified damages for wrongful termination. Care Initiatives has denied any wrongdoing and alleges that Schultz’s dismissal was based on legitimate, non-discriminatory, and non-retaliatory business reasons.

Inspectors detail events surrounding death

Some of the allegations in the lawsuit parallel the findings of state inspectors whose public reports describe the events leading up to Jacobs’ death.

According to the inspectors, an aide reported that Jacobs was sitting in his recliner when another worker noticed he appeared to be “in trouble” and instructed her to get a nurse right away. Jacobs was pointing at his neck, gasping for air, and mouthing that he could not breathe, the aide told inspectors.

The aide said she left the room to get the nurse and was absent for a few minutes. The worker who remained in the room later told inspectors Jacobs grew “really pale” and was gasping, so she, too, left the room and approached a nurse and said, “Would you please suction him? He needs to be suctioned.”

When the nurse entered the room, Jacobs was pale, but soon turned purple and then blue, the aide later reported. The nurse took his vital signs and told the aide Jacobs was having a heart attack. The aide explained to the nurse that Jacobs had been signaling he couldn’t breathe, at which point the nurse said, “Just a minute,” and left the room. The suctioning machine used to clear Jacobs’ airway sat idle on a nearby dresser, inspectors reported.

The nurse, later identified as Manning, told inspectors the “staff wanted me to suction him (and) I told the staff no. I was told that I would not have to do anything with the tracheostomy.” Manning allegedly told inspectors she first left the room to get supplies so she could check Jacobs’ blood pressure, pulse and oxygen levels and that when she returned, he was clammy and had an irregular pulse.

“I told the staff that I needed to go back to the nurses’ station and find out if the resident was a full code or DNR,” Manning reportedly told inspectors, referring to do-not-resuscitate orders that some residents have in place.

The inspectors allege that Manning told them that while she was checking on DNR order,  one of the aides approached her and said she was needed right away in Jacobs’ room. “I went back into his room and he had no blood pressure, no pulse, and no respirations. I pronounced him deceased,” she allegedly told inspectors.

She reportedly acknowledged her fellow workers had each told her Jacobs needed his airway suctioned and that he had been pointing to his neck and mouthing that he couldn’t breathe. According to the inspectors, Manning said that despite her colleagues’ comments, it never occurred to her to suction Jacobs’ airway.

Arbitration agreement blocks family’s lawsuit

Jacobs’ death is the focus of a separate lawsuit filed by his family against Fonda Specialty Care, Care Initiatives, Manning and the nursing home’s then-assistant director of nursing, Amanda Meyer.

According to the family’s lawsuit, when Manning arrived for work at the home on the afternoon of Feb. 18, 2023, she became aware Jacobs had a tracheostomy that would require suctioning at some point during the night and allegedly told Meyer and others she was unwilling or incapable of performing the work. Meyer allegedly told Manning to “watch a video and figure it out” and left the facility for the day, the lawsuit claims.

After the death, the family’s lawsuit claims, Manning falsely informed Jacobs’ son, Scott, that his father “went quickly and peacefully.” Scott Jacobs only learned of what actually transpired after being contacted by an Iowa Capital Dispatch reporter, the lawsuit claims.

The lawsuit alleges that after speaking to the reporter, Scott Jacobs called Jennifer Blair of Care Initiatives “to confront her about the (state’s) investigation and true facts of Pete Jacobs’ death.” According to the lawsuit, Blair “admitted to withholding information” from the family and not informing them of the state’s investigation and its findings.

Technically, the family’s lawsuit remains active, but all activity in the case has been stayed due to a judge’s finding that when Marvin Jacobs was admitted to the home, his son reviewed for 34 seconds an agreement that requires disputes over resident care to be settled through arbitration rather than the courts and then signed the document.

“The admittedly brief time he spent going over and eventually signing the arbitration agreement does not affect its validity or enforceability,” District Court Judge Michael D. Huppert ruled. Last week, the Iowa Supreme Court declined to review Huppert’s ruling.