Iowa Veterans Home Fined After Falls

Iowa’s nursing home for veterans has ended a program in which residents transported other residents who use wheelchairs around the campus, following a bloody accident in which an elderly woman fell face-first into concrete and broke her nose, its top administrator said.

The Iowa Veterans Home in Marshalltown reported the Sept. 29 fall by a resident who suffered from arthritis and dementia to state regulators and took responsibility for failing to train her escort. That incident and another in which a patient fell out of bed after being left unattended led the Iowa Department of Inspections and Appeals to cite the home for a major safety violation last month and fine it $3,000.

State records show it is the second fine for a serious violation in two years for the home, which is Iowa’s largest nursing home and among the biggest in the nation for veterans and their spouses. The home is made up of two separate facilities: one that provides nursing care for about 500 residents, and a residential care facility where 100 more people live mostly independently.

Under the home’s resident employee escort program, Commandant David Worley said Friday that about a dozen residents of the residential care facility were employed a few hours per week at minimum wage transporting nursing home residents in wheelchairs. He said the program had been in place for years but was discontinued after the Sept. 29 fall exposed a lack of training among employees and raised questions about safety.

“We hope we never, ever are the cause of a resident getting injured. That’s always our biggest concern,” he said. “We want that to never happen again.”

Asked why the escorts did not have training, Worley said the program was there when he took over as nursing home administrator 16 months ago “and we just hadn’t followed up on it.”

On Sept. 29, a male employee was transporting the woman back from a beauty shop down a ramp on the home’s grounds when she put her feet down, tried to stand up and fell face-first onto cement, records show. The woman taken to an emergency room, where doctors found her nose was broken and a major cut on her forehead that required 14 stitches.

The male employee told investigators he’d been doing the job for three months, but had no training on the proper use of wheelchairs.

“At the time of the fall, the wheelchair pedals were not being used and the resident escort employee transferring the resident had no training,” according to the state citation, which is dated Nov. 2. “The facility and/or director of nursing had not provided training to ensure residents’ needs were met.”

After the fall, Worley said employee escorts were reassigned to other jobs such as delivering mail and folding laundry. Residents in wheelchairs will now only be transported by staff employees or volunteers who go through training, he said.

David Werning, a spokesman for the Department of Inspections and Appeals, said the wheelchair escort program “may well have been a case of good intentions that went awry.” He said it was understandable to try to have residents feel good about helping others, but the lack of training was problematic.

In the second case, regulators faulted the home for failing to prevent a patient who had chronic kidney disease and other ailments from slipping off the end of a bed on Sept. 25 and hitting his or her head on the floor. That resident, whose gender wasn’t specified in the report, bruised the area around his or her eye so badly that it swelled shut and suffered abrasions to the elbow and knees.

Veterans home employees blamed a nurse for briefly leaving the resident sitting on the end of the bed while looking for another employee to help adjust the patient’s sling. The patient’s care plan had warned the resident was at high risk for falls.

Regulators cited the home for a single major violation as a result of multiple lesser infractions that constituted “an imminent danger or a substantial probability of resultant death or physical harm to the residents of the facility.”

The home paid the fine on Nov. 15, and its size was reduced by 35 percent to $1,950 under a policy rewarding violators who do not contest citations, Werning said. He said home administrators had also submitted an acceptable plan to address the problems, and regulators would check whether the measures are in place during a surprise visit.

“Anytime you get a Class 1 violation it signifies there is a significant issue to be corrected,” he said. “Considering the size of the facility, they jumped on it quickly.”

The home was cited and fined $4,500 last year for inadequate supervision after a resident with dementia left the grounds during a recreational activity, walked four blocks away and was spotted trying to hitchhike.