Lenox care facility cited

Following an August incident involving a resident being tied to a chair with a bed sheet, the Lenox Care Center has been cited with several federal fines.

The original $910,000 in federal fines has been reduced to $76,005. The fines are a result of violation of proper response and reporting of the incident to administration. State records indicate they have yet to be paid. If the facility chooses not to appeal the penalty, the fines will be reduced by 35%.

Lenox Care Center’s new administrator, Rae Tucker, declined to comment on the matter. The home is owned by Florida’s Arboreta Healthcare chain, which operates 21 care facilities in Iowa.

According to the state report by Department of Health and Human Services Compliance Officer Jolyn Meehan, the resident in question had diagnoses that included stroke and cancer.

The care plan stated there were indications she had a psychosocial adjustment issue due to recent admission. “She felt she was lied to regarding the admission as she thought she was going to a doctor’s appointment.”

Due to impaired cognition, new admission to the facility and threats to elope (leave the building unattended without staff knowledge or permission), the resident was a severe elopement risk.

According to progress notes, on Saturday Aug. 20, the resident was walking to each exit door, in and out of other residents’ rooms and grabbed and pinched the nurse. “She was very upset and unable to understand she was safe at the facility,” the notes stated.

Staff members said at approximately 10 p.m., the resident attempted to exit the building because the resident nurse (RN) had taken her cell phone for the night. Her family had requested her cell phone be taken away at night, but the RN had taken it earlier — at 7 p.m.

The RN grabbed the resident’s right arm, one hand at the elbow and the other under the armpit. The RN pulled the resident away from the entryway. The resident put up a struggle, and the RN let go, causing the resident to fall to the floor. Staff members said the RN moved the walker away from the resident and grabbed a chair.

“The resident was able to get herself up by using the door frame and that was when the RN grabbed the resident and put her in the chair,” one staff member said. “The RN stood in front of the resident while she was seated in the chair and put her hands on top of the resident’s shoulders and slammed the resident onto the chair.”

The resident began to yell and try to pry the RN’s hands off the shoulders when the RN asked a certified nursing assistant (CNA) that had just began their shift to grab a bed sheet. During that time, the CNA heard the RN say, “There’s no reason for this, we are not a memory care unit. We are not equipped for this.”

The CNA said she didn’t think anything of grabbing the sheet because they had previously used bed sheets to absorb water spilled on the floor before getting a mop.

“The RN put the sheet over the chair’s arms, folded it in half and looped it through the spaces of the arm rests,” the CNA reported.

It was at that point the two staff members getting ready to leave for the night stepped out to call the director of nursing. The director said she had just taken sleeping pills and could not come in to help.

“She was crying and screaming out help me,” one of the residents described. He said the RN was difficult to work with and said she is “vindictive.”

Despite consistent staff testimony, the RN denied many of the allegations, saying they linked arms and walked away from the entryway while she patted the resident’s hand. She said the resident sat down in the chair of her own volition.

In response to the resident falling, the RN said she did not fall, but knelt down on her knees and prayed for her phone to be returned. The RN said she asked for a bed sheet, but didn’t use it because she couldn’t do that.

The RN reported being at her “wit’s end” since many call lights were going off at the time, but the resident required both staff members’ attention.

The director of nursing stated she had never worked with the RN because the RN worked the overnight shift.

The director did not inform the administrator of the events until Monday Aug. 22 — two days later when she sent a text detailing the situation. When interviewed later by inspectors, the director of nursing acknowledged she should not have waited two days to report the incident to the administrator, saying she had never had anyone do that before and did not know what to do.

The administrator then came in, got statements and completed her initial report.

The facility policy titled Abuse Preventions Program and Reporting Policy indicated staff are to immediately separate the resident from the alleged perpetrator. If a direct caregiver is suspected of allegedly abusing a resident, the administrator or director of nursing must immediately suspend individual without pay until the investigation is complete.

Findings concluded the facility failed to follow these protocols.

The state inspection report gives no indication as to whether the Lenox Care Center disciplined any workers involved in the incident, or whether the matter was referred to a licensing board, police or prosecutors.