State again fails to impose legally mandated fine after nursing home death

The state agency that oversees Iowa’s nursing homes has again failed to impose the legally mandated fines against a repeat-offender care facility.

It’s at least the second time in four months that the state has failed to impose the minimum fine against an Iowa care facility implicated in the death of a resident.

State records show that earlier this month, the Iowa Department of Inspections and Appeals cited Lantern Park Specialty Care in Coralville for violations that contributed to a resident’s death from an infection. DIA fined the home $10,000 for failing to provide residents with the required nursing services, plus $10,000 for separate violations related to resident safety.

Six weeks earlier, in January, Lantern Park was cited for failing to provide residents with the required nursing services. In that case, the home was accused of failing to suction a resident’s airway as needed. The resident had been hospitalized at least three times due to the failure, and allegedly told inspectors, “It makes me feel like they don’t care if I can breathe or not.”

Because the home was twice cited for the same high-level offense — failing to provide the required nursing services – within a one-year timeframe, DIA was required by law to have tripled the more recent $10,000 fine for the violation but did not do so.

On Tuesday, the Iowa Capital Dispatch asked DIA officials about the failure to triple the fine. DIA then posted to its website a revised citation indicating the $10,000 fine for the nursing-services violation had been tripled to $30,000, with the $10,000 fine for safety violations remaining the same.

A similar situation occurred in early 2020, when the Capital Dispatch asked DIA about a $7,250 fine that had been imposed against the Rowley Memorial Masonic Home in Perry. DIA inspectors had cited the home for contributing to a resident death, hiring an unlicensed caregiver, failing to protect residents from sexual abuse and allowing a kitchen worker to supervise its dementia ward.

The $7,250 fine against the home should have been tripled to $21,750 because of previous, recent citations for the same violations. DIA blamed a “clerical oversight” for the lower fine, and subsequently increased the penalty against Rowley to $21,750.

In January of this year, DIA officials imposed a state fine of $17,500 against Mount Pleasant’s Arbor Court care facility. As in the Rowley Memorial Masonic Home case, the Capital Dispatch asked DIA why the fine against Arbor Court appeared not to have been tripled despite a recent citation for the same violation. In that case, the department said the staff had mistakenly doubled what was intended to be an $8,750 fine to $17,500, when the fine should have been tripled to $26,250.

After the incident in January, the Capital Dispatch asked DIA officials whether the agency had “a system in place to eliminate, or at least minimize, errors of this kind.” The agency did not respond.

The state fines against nursing homes are often largely symbolic since they are held in suspension to give the federal Centers for Medicare and Medicaid Services an opportunity to impose a federal penalty.

Lantern Park case involves a death

The most recent case involving Lantern Park Specialty Care involves allegations that the home failed to properly assess and treat a resident’s urinary tract infection, or inform a physician of the situation, which led to the resident being sent to a hospital where she died.

The home also failed to see to it that a resident with anemia was provided with his prescribed blood transfusions, state inspectors allege.

According to the reports of DIA inspectors, lab tests for a female resident of Lantern Park were conducted on Jan. 23 and indicated the woman had a urinary tract infection. Over the next three days, however, the staff allegedly failed to check on the woman and assess her condition.

On Jan. 26, the woman’s daughter came to the facility and couldn’t wake her mother. An ambulance was summoned to take the woman to the hospital, with one nurse later telling inspectors she noticed a strong odor of urine as the woman passed by on the ambulance gurney. The ambulance crew later informed the woman’s power of attorney it was apparent the woman had been sitting in her own urine for hours, and the emergency room nurses described the woman as “soaked in urine” upon her arrival there.

Later that same day, the woman’s temperature reached at 105.8 degrees and she died that afternoon.

It was determined the woman had a urinary tract infection with sepsis, a potentially fatal infection, and a white blood cell count of 24.6, which was far in excess of the normal range of 4.5 to 11.

The day after the woman died, on Jan. 27, a 72-year-old male resident of the home was taken to a hospital after being seen at a cancer center where he received regular blood transfusions. A hospital physician reported the man was disheveled and weak, and said that for the past month the man had missed all of his weekly appointments for transfusions. The man’s hemoglobin level was 4.8 at the time. For men, a level of 13.5 or below is considered dangerously low.

A Lantern Park nurse told state inspectors she did not know how often the man was supposed to be taken to the cancer center for treatments and noted that while such appointments should be written in a book, “some days are really busy” and residents’ medical appointments aren’t recorded.

The assistant director of nursing told inspectors the man may have missed his appointments because they weren’t recorded in the appointment book or because the facility simply could not get him a ride. She acknowledged, however, that she was unaware the man was supposed to go to the cancer center once every week, according to inspectors.

Lantern Park is owned and managed by Care Initiatives of West Des Moines.