Again, a scene was cited where a woman died with her head on the bed rails. • Iowa Capital Dispatch

An Iowa nursing home where a woman died screaming for help with her head stuck in the bed rails was cited for additional violations.

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

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

The previous violation involved the death of a resident

In August, the state cited Lutheran Living for failing to protect residents from threats. The proposed $10,000 state fine was tripled to $30,000 because the security violation was a repeat offense, but the fine was suspended due to the possibility of a federal fine.

Although 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.

On February 11, at approximately 4:30 a.m., a certified nursing assistant at Lutheran Living reportedly heard a resident screaming for help, but determined it was nothing serious and went on rounds. A short time later, another CNA walked through the woman’s room and saw that the woman was half out of bed and unresponsive. The CNA told inspectors that she sought help from the nurse, who told her she was not responsible for the woman and instructed her to notify the CNA assigned to that room.

About five or 10 minutes later, 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 her upper body on the bed. According to inspectors, the woman’s head was between the mattress and the side rails attached to the bed.

One CNA reportedly told inspectors that she thought the woman had been crying earlier because her “head was stuck” and she couldn’t get up.

Inspectors: The home was understaffed

From interviews with staff, state inspectors learned that the home was understaffed that evening, in part because two CNAs had left the facility early in the middle of their shift. One of the earlier 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 evening told inspectors the home was understaffed. The LPN claimed that she called the assistant director of nursing at home that evening to ask for help, but the assistant director of nursing refused to come to work and told her to “think better of it.”

When the deputy director of nursing was asked about this, she allegedly told inspectors that no such request had ever been made, and the director of nursing interjected, stating that there was “no evidence” that such a call had been made.

However, inspectors said they later reviewed the personnel file of the deputy director of nursing and discovered she had been reprimanded for failing to report to work when called on the night of the death.

The written reprimand allegedly states that on the night of the death, the associate director of nursing “was called twice due to concerns about understaffing on the night shift” and that she directed two nursing assistants to guard two hallways, despite “repeated” recommendations that the CNA not they should do this. The reprimand allegedly goes on to state that the assistant director of nursing “failed to discharge his on-call duties” that evening and placed the resident’s care at risk.

Although three employees told inspectors the night of the death that the home was understaffed, the Iowa Department of Inspections and Appeals found no staffing violations at the facility.

The 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 says the agency has fined the home a total of $7,150 over the past three years, while all state fines have been suspended.

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