Iowa nursing home death caused by lack of oxygen leads to $8,500 state fine
The staff at an Iowa nursing home neglected to replace a resident’s depleted oxygen tank last month, resulting in the woman’s death, according to state inspectors.
The Iowa Department of Inspections, Appeals and Licensing has fined Odebolt Specialty Care in Sac County $8,500 as a result of the death.
The nursing home, which is owned and operated by the West Des Moines nursing home chain Care Initiatives, allegedly failed to provide adequate oxygen for a female resident diagnosed with congestive heart failure and who required supplemental oxygen. The inspections department alleges the staff repeatedly failed to monitor the woman’s vital signs and failed to check her oxygen tank to ensure she could breathe.
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Inspectors’ reports indicate that when workers at the home approached the woman to take her to lunch on the morning of Dec. 20, they found her unresponsive with an empty oxygen tank nearby. The reports state the woman’s oxygen saturation level ranged from 12% to 45%. Anything below 88% typically calls for immediate medical intervention.
The woman was transported to a hospital where she was diagnosed with an anoxic brain injury, a condition caused by a lack of oxygen. The hospital transferred the woman by air to a larger hospital where she died a few days after admission.
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According to the state inspectors, the woman’s clinical record at Odebolt Specialty Care indicates the staff there failed to check and record the woman’s oxygen saturation levels in the days leading up to her hospitalization, a period in which she had displayed erratic behavior, odd facial expressions, and signs of lethargy — all potential signs of oxygen deprivation.
Workers later told inspectors they had not checked the resident’s oxygen tank to see whether it was switched on or the oxygen tank was depleted. The director of nursing reportedly told inspectors that she expected the staff to check whether the oxygen supply was functioning but added that she “didn’t know for sure what kind of education” the staff had on the use of the device.
Two nursing assistants allegedly told the inspectors they didn’t recall receiving any education or training on residents’ use of oxygen concentrators and tanks.
Another resident's wound allegedly allowed to 'tunnel' into flesh
State inspectors also cited Odebolt Specialty Care for repeatedly failing to assess and treat a wound on the leg of another resident last May, resulting in the wound growing or “tunneling” into her flesh.
A nurse practitioner from a local hospital later told inspectors the wound was “horrible” with tunneling throughout the full length of the leg, adding that the woman had been admitted to Odebolt Specialty Care with a wound vacuum and specific instructions for the staff to periodically change the wound dressing. The nurse practitioner allegedly said she knew no one at the nursing home had changed the dressing as it still had the original date markings on it.
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State inspectors concluded the home had assessed the wound only twice: on the day of the woman’s admission and, 19 days later, the day of her discharge. The inspector’s report gives no indication as to whether the resident survived or was hospitalized.
It’s not clear why the investigation of the May 2023 incident didn’t take place until December 2023. State records indicate that when the inspectors visited the facility in December, they were responding to a backlog of four separate complaints, all of which were substantiated.
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This article originally appeared on Des Moines Register: Nursing home death caused by oxygen deprivation draws $8,500 Iowa fine
