MUSCATINE, Iowa — For the second time in 12 months, Lutheran Homes Society has been cited for multiple regulatory violations,  including incidents in which patients suffered harm or were placed in jeopardy.

Citations were issued after 19 deficiencies were founded this year, according to the Iowa Department of Inspections and Appeals. Concerns arose during an on-site survey in September in which 15 deficiencies were noted. During a complaint investigation in October, two deficiencies were noted and the facility was cited.

Two deficiencies were found in January, but the facility was not cited for those because they did not meet the threshold.

Andy Edeburn, senior marketing consultant for Health Dimensions Group, said Tuesday that the most severe incidents reported were isolated incidents and that Lutheran Homes is back on track.

Health Dimensions Group of Minnesota is a management company hired by Lutheran Homes’ Board of Directors in September 2007 to rectify unstable leadership and provide more training and structure.

“The quality of care at Lutheran Homes remains exemplary,” Edeburn said. “They’ve taken extensive measures to assure it doesn’t happen again.”

What happened?

According to reports from Iowa Department of Inspec-tions, it was determined that:

- A resident received second-degree burns in July from a hot pack that was needed due to a fall that caused a back injury. The hot pack instructions read that it was to be left in place for 30 minutes, but instead it was left on overnight.

The resident remained at Lutheran Homes after the incident and it was reported in August that the burn wasn’t cared for properly. The resident contracted Methicillin-resistant Staphylococcus aureus (MRSA), a highly contagious and potentially dangerous infection resistant to penicillin, after the burn was improperly treated.

This incident, along with others, posed an immediate risk to the health or safety of residents, according to the Department of Inspections.

- A resident broke a hip and wasn’t taken for three days to have X-rays.

Instead, the resident was placed in a wheelchair and given Tylenol for three days, according to the state report. The person reported severe pain, refused to eat because of the pain and was “crying out with movement.”

Lutheran Homes was fined $3,000 for the incident.

“Staff failed to recognize the problem and provide an appropriate assessment for intervention,” said David Werning, Inspections and Appeals spokesman.

Werning added that there is now a $10,000 federal penalty against Lutheran Homes as a result of survey findings in September for failure to protect residents from hazards.

Other reported deficiencies that occurred in 2008 include:

- Giving at least one resident improper medication or dosage.

- Failing to ensure that the residents’ environment is free from accident hazards and that each resident receives adequate supervision and assistance to prevent accidents.

In January, a resident suffered a broken arm after falling. Another resident suffered a blow to the head after falling due to an improperly secured seat in the whirlpool. Other residents have fallen with less-severe injuries and at least one fall was not reported properly, according to the state report.

- Failing to provide all residents with scheduled range-of-motion therapy as scheduled, possibly resulting in the stiffening of some patients’ joints and limbs. In interviews, multiple staff members agreed they were unable to perform the therapy on most days because of inadequate staffing.

- Failing to provide preventative wound care in at least one instance pertaining to pressure or bed sores. 

- Failing to help at least one resident with daily hygiene and care needs.

- Failing to properly clean  residents’ private areas and and inner thigh areas when they needed assistance after using the restroom.

- Failing to maintain infection control by leaving soiled linens lying on the floor. At times, the linens were soiled by residents with MRSA. There were also incidents of contaminated glucometers taken from room to room and at least one instance of a staff member failing to wash his or her hands after wiping up feces.

- Failing to have, or properly use, a resident-call system and alarm equipment in multiple areas of the facility.

- Failing to dispose of expired medications, according to Iowa Code.

- Failing to provide necessary maintenance and housekeeping services to maintain a sanitary, orderly and comfortable interior.

Some of the issues are pending and under appeal.

The facility has been fined $250 a day since Oct. 24, and will continue to be fined until it is in compliance. A date has not yet been set for the state to inspect the facility again.

Also, the federal government has issued a denial of payment, which began Oct. 4, for any new resident whose stay is paid for or reimbursed by Medicare or Medicaid.

In November 2007, it was reported that Lutheran Homes had been cited for dozens of violations, including failure to properly treat open wounds. It was also reported that the staff allegedly waited in excess of 30-50 minutes to answer patients’ call lights.

The facility was fined by the state and penalized by the federal government for those instances.

Another issue involved a patient’s death in August 2007 that led to a $3,000 fine for the home for failure to provide “accurate assessment and timely intervention.”

Fixing the issues

Edeburn said Tuesday that Lutheran Homes administrator Diane Peters was out of town and he couldn’t go in to great detail about the deficiencies. Phone calls to Peters’ cell phone were not returned as of press time Friday. Edeburn did comment that severe incidents, including the burn and the broken hip, are extremely unfortunate and isolated.

Lutheran Homes has “filed a plan of correction with the state and (we) expect to be cleared on all of the tags within the next few days,” Edeburn said.

He added that the care at the facility should be trusted and if anyone has a concern about the incidents they should contact Peters at Lutheran Homes.

Werning said some problems identified may or may not be pertinent to every resident but still need to be resolved. Most of what was reported, other than the burn and broken hip complaints, were matters of an isolated, yearly survey visit, he said.

Werning added that accidents can happen anywhere, but multiple deficiencies can become concerning.

“It’s a snapshot in time. People are encouraged to look at the statement and history of the facility in order to make their own judgments,” he said

Reporter contact information

Melissa Regennitter: 563-262-0526

or mregennitter@muscatinejournal.com