Hospital reports Cedar Rapids nursing home for ‘abuse’ related to resident care

A Cedar Rapids nursing home has been fined $13,000 after a series of alleged medication errors.

According to state inspection records, on May 23, a resident of Heritage Specialty Care, at 200 Clive Dr. SW, erroneously received 12 medications that were to have been administered to another resident.

The resident who received the medications later became lethargic and confused and their oxygen saturation levels dropped, inspectors allege. The resident was taken by ambulance to a hospital, where they were admitted to the intensive care unit and treated for medication-type poisoning. The resident was hospitalized for four days, according to the inspectors’ reports.

The nurse who had administered the drugs reportedly told inspectors she had to give medications to 13 residents that day, there were a lot of call-lights on due to residents needing assistance, and she was the only nurse on duty at the time and was being assisted by one nursing assistant.

A few weeks later, on June 4, the facility allegedly failed to properly assess a female resident and intervene after the woman became unresponsive and was sent to the hospital with a blood glucose level of 25 — anything below 54 is considered dangerous, requiring immediate action — after being given insulin without eating their meal.

Inspectors reported that they were unable to observe the resident during their investigation, which took place in early July, because “she was still hospitalized during the investigation.”

In their written findings, the state inspectors said that when they asked Heritage’s director of nursing “what he felt the cause of the error was, he reported he did not think there was an error.”

The hospital involved in the incident reported Heritage Specialty Care for alleged abuse related to neglect that resulted in a hypoglycemic resident, according to state inspectors.

Six days after that incident occurred, on June 10, an employee of Heritage Specialty Care incorrectly administered 12 or 13 units of insulin for a resident rather than the expected 17 units, inspectors reported. The resident soon became unresponsive with a blood glucose level of 25 and was sent to a hospital for treatment, inspectors alleged.

Heritage Specialty Care is part of a chain of nursing homes operated by Care Initiatives of West Des Moines. A company representative said Tuesday that she was not able to comment at that time on the state’s findings.

Woman dies after fall, medication error

An assisted living center where a resident died after a fall and being given the wrong medication has been fined $6,000 by the state.

State inspection records indicated that a female resident of MeadowView Memory Care Village, 3005 F Ave. NW in Cedar Rapids, fell to the floor on the evening of Nov. 15, 2024, and was taken to a hospital for an evaluation. The hospital reported no acute medical issues and the resident returned to MeadowView.

The next day, the MeadowView staff reported the resident was groggy and sleepy, and was not eating or walking as she normally would be. The resident also appeared to display weakness on one side and was yelling out in pain while holding her head in her hands and rocking back and forth.

“The screaming/yelling became more intense around 5 p.m.,” inspectors later stated in their report, referencing interviews with the MeadowView staff. Around 6:30 p.m., which was roughly 24 hours after the fall, a nurse realized she had mistakenly given the woman another resident’s medications.

The resident sat in a wheelchair near the nurses’ station, yelling and crying “off and on until around 8:30 p.m., when she began to get drowsy and sleepy,” inspectors reported. Around 9:30 p.m., the inspectors reported, the staff noticed the woman was no longer breathing. A nurse was summoned, did an assessment and pronounced the woman dead.

According to inspectors, the Linn County medical examiner later reported that he didn’t remember anyone telling him of the medication error while adding that he believed the medications involved would not have caused the woman’s death. The medical examiner indicated he suspected the resident had a stroke that might have been connected to the fall the day before her death.

The resident’s primary care provider allegedly told inspectors she was not informed the resident was weak on one side, unable to walk, was yelling in pain, and holding her head and rocking back and forth, adding that such behavior could have been symptoms of a stroke. Had she been informed, she reportedly told inspectors, she would have considered sending the resident back to the hospital for a brain scan.

Dallas Urbain, a manager with MeadowView, said the correct administration of medication and the prompt reporting of a patient’s change in condition are among the facility’s highest priorities and any errors that occur are taken seriously. In this instance, she said, corrective action, including staff training, was taken.

This article originally appeared in the Iowa Capital Dispatch.