Home where woman died with head in bed rails is cited again

An Iowa nursing home where a woman died while calling for help with her head caught in her bed rails has been cited for additional violations.

On Oct. 10, state inspectors cited Muscatine’s Lutheran Living Senior Campus for an incident in August in which a resident with dementia left the facility undetected in his wheelchair. The resident’s wheelchair tipped over, spilling the resident onto the grass, and a visitor alerted the staff to the situation.

The state proposed a $6,750 fine for failing to protect residents from harm. Because it is a repeat violation, the proposed fine has been tripled to $20,250 but it has also been held in suspension to allow the federal government to consider imposing a fine of its own for the violation.

Previous violation involved resident death

In August, the state cited Lutheran Living for failing to protect residents against hazards. A proposed $10,000 state fine was tripled to $30,000 due to the safety violation being a repeat offense, but the penalty was held in suspension due to the potential for a federal fine.

While the citation for failing to protect residents from hazards was issued in August, the death that prompted the citation occurred six months earlier, in February 2024.

About 4:30 a.m. on Feb. 11, a certified nursing assistant at Lutheran Living reportedly heard a female resident yell for help, but believed it was nothing serious and went about her rounds. A short time later, another CNA passed by the woman’s room and saw the woman half out of bed and unresponsive. That CNA told inspectors she sought assistance from a nurse who told her the woman was not her responsibility and instructed her to notify the CNA who was assigned to that hall.

About five or 10 minutes later, the two CNAs went to the woman’s room and found her face down on the bed, with her lower body near the floor next to the bed, and the upper part of her body on the bed. The woman’s head was between the mattress and the side rails attached to the bed, according to inspectors.

One of the CNAs reportedly told inspectors she thought the woman had cried out earlier because “her head was stuck there” and she couldn’t get up.

Inspectors: Home was short-staffed

Through interviews with the staff, the state inspectors learned the home was short-staffed that night, in part because two CNAs had left early in the middle of their shift. One of the early departures was expected, but the other was the result of an unexpected medical emergency.

According to state reports, two nurse aides and a licensed practical nurse who were on duty that night later told inspectors the home was short-staffed. The LPN alleged she called the assistant director of nursing at home that night to ask for assistance, but the assistant director of nursing refused to come into work and told her to “figure it out.”

When the assistant director of nursing was asked about that, she allegedly told inspectors no such request was ever made and the director of nursing chimed in by stating there was “no proof” any such call was made.

However, inspectors reported that they later reviewed the personnel file of the assistant director of nursing and discovered she had been reprimanded for failing to come into work when called on the night of the death.

The written reprimand allegedly indicates the assistant director of nursing “was called two times with concerns over lack of staff on the night shift” on the night of the death, and that she had instructed two nurse aides to cover two hallways, despite “multiple” advisories that CNAs were not to do so. The reprimand allegedly goes on to say the assistant director of nursing “failed to fulfill their on-call responsibilities” on the night in question and had placed resident care at risk.

Although three workers reportedly told inspectors the home was short-staffed the night of the death, the Iowa Department of Inspections and Appeals did not cite the facility for any staffing-level violations.

Lutheran Living Senior Campus currently has a one-star rating for overall quality on the Centers for Medicare and Medicaid Services’ five-star scale. CMS reports that in the past three years, the agency has fined the home a total of $7,150, while all of the state fines have been held in suspension.

The Iowa Capital Dispatch was unable to reach the home’s administrator, Andrew Harris, for comment. Calls to his office were not immediately returned on Monday.