Storm Lake nursing home fined $31,500 for resident’s fatal fall

An Iowa nursing home where a former school teacher suffered a fatal head injury after falling from a mechanical lift is now facing a $31,525 fine.

In June, the Iowa Department of Inspections and Appeals cited North Lake Manor of Storm Lake for failing to protect residents from harm and failing to provide adequate care. Workers at the home told inspectors they were overworked and had no time to give residents their baths or tend to some of their medical needs.

State records and local police reports indicate that on May 17, the staff was using a mechanical lift to transfer 87-year-old Darlene Carbaugh into her bed. The device apparently malfunctioned, and Carbaugh tumbled out of the lift, landing head first on a concrete floor, the home’s workers told inspectors.

Carbaugh remained alert, but according to state records, she soon was anxious and crying, and then began yelling, “Help me!” as EMTs loaded her into an ambulance. While en route to the hospital, Carbaugh asked the EMTs several times if she was going to die. After arriving at the hospital, she was diagnosed with significant bleeding in the skull, lapsed into a coma and died the next day.

Workers at the home later told inspectors that the part of the mechanical lift that appeared to have failed belonged to a different lift that was made by another company, according to state records.

Carbaugh was a former Iowa school teacher. She and her husband, Alfred, had lived in Spirit Lake since 1950, where they raised two sons. Alfred was a veteran of World War II and died in February 2013.

The state initially imposed a $24,500 fine against the home — the sixth-highest state fine against an Iowa care facility during the past 12 months. But that penalty was set aside in lieu of a $3,800-per-day fine imposed by the federal Centers for Medicare and Medicaid Services for every day the home remained out of compliance with minimum care standards.

After 12 days, the daily penalty was reduced to $100, and it remained at that level for 29 days. On July 16, CMS officials informed the facility’s owners they owed a total of $48,500 in fines. But because the owners have agreed to forgo an appeal, CMS has discounted the federal fines by 35 percent, resulting in a final penalty of $31,525.

North Lake Manor is owned and operated by two limited-liability companies, JP Senior HealthCare and JP Senior Management. The companies’ corporate address is the residence of Joseph P. DeWitt, a 58-year-old Sioux City accountant.

DeWitt’s companies also own or manage Goldenrod Manor in Clarinda and Pocahontas Manor in Pocahontas.

Company officials referred all questions to attorney Lynn Boes of Des Moines. Boes did not respond to emailed questions about JP Senior HealthCare or the state’s findings.

When state inspectors arrived at North Lake Manor to investigate Darlene Carbaugh’s death, they met with several residents who complained that the facility was frequently short-staffed. They complained of not receiving physical rehabilitation services, being left to sit or lie in their own urine, and going weeks without baths.

With the state inspectors on site, it took the staff 30 minutes to answer one resident’s call light. A check of that resident’s file indicated the staff documented the resident getting a whirlpool bath that morning. But further checking revealed the resident was simply “wiped down” by an aide while the resident sat on the toilet.

Facility records showed another resident had received one bath in the month of May. Another resident reported lying in urine-soaked bedding for 105 minutes that morning after the staff ignored his or her call light. “It makes me feel crappy — like, ‘What am I doing here?’ ” the resident told inspectors.

During the inspection, a group of four nurse aides met with an inspector to express their concerns. They said there weren’t enough caregivers on staff and they had no time to give residents their baths or their exercises. Later that day, an administrator for the home told inspectors the facility had enough staff and that the real problem was that the workers weren’t doing what they were trained to do.

Check reports on nursing homes

Information on Iowa nursing homes is available at the following websites:

• The Iowa Department of Inspections and Appeals publishes the actual on-site inspection reports for nursing homes on its website. To read the reports, go to dia-hfd.iowa.gov/DIA_HFD/Home.do and click on “Report Cards.” You can search for inspection reports by facility name or location.

• The Centers for Medicare and Medicaid Services scores all Medicaid-certified care facilities by several criteria — although some of the data used for those scores are self-reported by the facilities. Go to www.medicare.gov/nursinghomecompare.