Iowa-run home in Glenwood cited for another death and a major COVID-19 outbreak

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HR King
May 29, 2001
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For second time this year, the state-run Glenwood Resource Center for people with disabilities is facing fines related to the death of a resident.


The western Iowa care facility, which is run by the Iowa Department of Health and Human Services, is also being cited for failing to implement basic infection-control protocols in the midst of a recent COVID-19 outbreak that left more than 90 residents and workers infected.


Glenwood has been cited for an increasing number of violations this year. The most recent set of inspectors’ findings relate to a 64-year-old female resident of the home with a profound intellectual disability.


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On May 16, at 9:10 a.m., Glenwood’s respiratory therapist checked the woman’s pulse and noted in a medical chart that the woman’s heart rate was 41, well below the normal adult range of 60 to 100 beats per minute.


Although there was an order in place requiring the staff to alert nurses or a physician if the woman’s heart rate ever fell below 60, the therapist later acknowledged she informed no one of the woman’s condition.


At 12:39 p.m., the staff found the woman unresponsive in her recliner. The staff called 911, initiated CPR, and had her taken to the hospital, where she was pronounced dead.


On July 28, two months after the woman’s death, the Iowa Department of Inspections and Appeals investigated the matter and determined that residents of the home were in “immediate jeopardy.” That same day, the home developed a training plan and DIA removed the immediate jeopardy status the next morning.


During their July visit, inspectors noted that another woman at the home had a history of breast cancer, with a mastectomy of her right breast in 2006, and was to receive mammograms annually. Although the woman was considered a “high-risk patient” with regard to cancer, the Glenwood staff was unable to locate any record of mammograms for the woman after 2019.


In addition, Glenwood was cited for failing to implement protocols to prevent the transmission of COVID-19 in the home. According to the inspectors, 46 of the home’s 147 residents, and 47 of the home’s 546 employees, tested positive for COVID-19 between June 5 and Aug. 3. Four of the 46 COVID-positive residents had to be hospitalized for respiratory issues.


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The inspectors’ report states that the superintendent of Glenwood confirmed that workers were self-screening before the beginning of their shifts and verified that there were no additional screening methods being used, even during the COVID-19 outbreak.


Many of the Glenwood residents have respiratory problems and other conditions that can be exacerbated by COVID-19.


Glenwood was fined $7,500 as a result of the most recent inspection, but because the home agreed not to appeal the penalty, the fine was reduced to $4,875.


Violations increasing as home prepares to close​


The Glenwood Resource Center has a long history of quality-of-care issues and is scheduled to close in 2024.


In April 2022, the home was cited for one violation; in May, it was cited for two violations; in July, it was cited for four violations; and this month the home was cited for seven violations.


In February 2022, a 30-year-old resident of the home died of acute dehydration after facility staff failed to monitor his fluid intake. In January, Glenwood was cited for an incident in which a worker allegedly yelled at a resident and shoved a plate in the resident’s face. In May 2021, Glenwood was cited for failing to employ sufficient staff to manage and supervise residents.


Five weeks ago, DHHS spokesman Alex Carfrae said the state agency had taken “immediate action to remediate the concerns” raised by inspectors at that time. “We continue to work closely with DIA to ensure we properly train employees and do not see repeat mistakes that compromise safety,” Carfrae said then.


The violations stemming from the August inspection have resulted in citations for inadequate staff training programs; failure to provide sufficient direct-care staff to manage and supervise residents; inadequate health care services; failure to provide an annual physical examination of each resident; inadequate nursing services; medication errors; and a lack of infection control.


Asked about state inspectors’ latest findings. Carfrae said on Friday that DHHS has “worked closely with state regulators to ensure the best possible care at the state resource centers” and has now developed “enhanced measures to increase accountability and oversight for resident care.”


With regard to the COVID-19 outbreak, Carfae said the agency “follows recommended mitigation protocols for COVID-19 in our facilities,” contradicting the findings of state inspectors. He added that Glenwood residents who test positive are isolated and enhanced cleaning measures are undertaken to ensure the safety of other residents.


In 2019, the U.S. Department of Justice opened a two-part investigation into the Glenwood and its sister facility, the Woodward Resource Center, focusing on quality of care and the state’s overreliance on institutional settings for serving people with disabilities.


In December 2020, the DOJ released a report that concluded the state of Iowa had subjected Glenwood residents to “unreasonable harm” through uncontrolled and unsupervised physical and behavioral experiments and through “inadequate physical and behavioral health care.” The decline in care at Glenwood, the DOJ reported, “was facilitated by a DHS Central Office that was unwilling, unable, or both, to recognize and address the problem.”


In April, Gov. Kim Reynolds announced plans to close Glenwood in 2024, having concluded that the state cannot meet the DOJ’s expectations for resident services.


“Iowans with intellectual and developmental disabilities deserve quality care that aligns with the expectations of the DOJ,” Reynolds said in April. “Our best path forward to achieve those standards is closing GRC and reinvesting in a community-based care continuum that offers a broad array of services.”


This article originally appeared in Iowa Capital Dispatch.