The Glenwood Resource Center has been cited for subjecting a disabled resident to a life-threatening lack of oxygen. (Photo via Google Earth)

Weeks after a disabled resident of the state-run Glenwood Resource Center died due to a lack of water, another resident of the home was subjected to a life-threatening lack of oxygen, state records show.

In early June, the western-Iowa facility was cited after a 30-year-old resident of the home died of acute dehydration when the facility staff failed to monitor his fluid intake. The home was fined $10,000 – later reduced to $6,500 — by the Iowa Department of Inspections and Appeals.

Two weeks ago, DIA cited Glenwood for having placed residents in immediate jeopardy based on a failure to train and supervise the staff and a failure to follow physician orders related to a resident’s oxygen.

The center has a long history of care issues and is scheduled to close in 2024. It is run by the Iowa Department of Human Services, the same state agency that’s charged with protecting the health and welfare of children and dependent adults in Iowa.

The resident who died had a profound intellectual disability as well as cerebral palsy. He was hospitalized for eight days in November 2021 due to dehydration and a resulting acute kidney injury. Upon his return to the home, inspectors said, the staff repeatedly failed to provide the man with the prescribed amount of water each day. He died in February after being diagnosed with acute dehydration, a urinary tract infection and cardiac arrhythmia.

At the time, inspectors determined there was “a lack of training” at Glenwood to ensure the staff followed each resident’s care plan.

The more recent incident was investigated by state inspectors in late June, which led to a $7,750 fine and a conclusion that Glenwood had “failed to provide adequate and ongoing training and oversight to ensure staff competency.”

Those findings are tied to an incident in April, when a residential treatment worker entered the room of a 48-year-old male resident and noticed the man was gasping for air. The man’s skin was gray in color, his lips were blue, and his eyes were glassy, the worker later reported. The employee immediately notified two nurses who came to the room and discovered the resident’s supply of supplemental, bottled oxygen was switched off.

A review of video footage indicated the resident’s oxygen had been shut off three hours earlier and workers who subsequently checked on him had failed to notice.

According to inspectors, the footage shows the oxygen was shut off and disconnected at 12:22 p.m. when the man was moved from a common area to his bedroom. At 12:32 p.m., a nurse walked into the man’s room, suctioned his airway to prevent any blockage, and left two minutes later without noticing his oxygen supply  was turned off.

At 12:44 p.m., a worker walked into the room, was there for 10 seconds, and then left. At 2:20 p.m., two workers walked down the hallway and passed the man’s bedroom. At 2:38 p.m., a worker stood at the doorway and looked in at the man.

It wasn’t until 3:17 p.m. that the residential treatment worker entered the room, observed his condition and summoned the two nurses. The man’s oxygen-saturation levels had dipped to 62% — well under the 70% threshold that is considered life threatening.

Once the oxygen was switched on, the man’s vital signs improved, and his oxygen-saturation level increased to 100%.

Physician orders that were in place at the time of the incident called for the staff to visually check on the man every 15 minutes. An inspector interviewed one of the Glenwood workers who stated that she and a colleague worked on residents’ charts and on a puzzle until the afternoon-shift workers arrived. According to the inspector, the employee said she and her colleague had failed to check on the man “because they were being irresponsible.”

Both the Feb. 18 dehydration death and the April 13 oxygen-deprivation incident were investigated by DIA three months after they took place. The agency has acknowledged it is dealing with a significant backlog of complaints and self-reported incidents to investigate.

As of last month, there were 410 complaints pending against Iowa nursing homes that were at least 30 days old. Of those, 201 complaints – almost half the total number — were more than 120 days old. In fact, 24 of the pending complaints against Iowa nursing homes were more than one year old, according to DIA.

In January, the Glenwood Resource Center was fined $2,750 after 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 fined $2,750 for failing to employ sufficient staff to manage and supervise 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 over-reliance 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 of this year, Gov. Kim Reynolds announced plans to close Glenwood in 2024, having concluded that the DHS cannot meet the Department of Justice’s expectations for resident care.

by Clark Kauffman, Iowa Capital Dispatch July 15, 2022

by Clark Kauffman, Iowa Capital Dispatch July 15, 2022

Weeks after a disabled resident of the state-run Glenwood Resource Center died due to a lack of water, another resident of the home was subjected to a life-threatening lack of oxygen, state records show.

In early June, the western-Iowa facility was cited after a 30-year-old resident of the home died of acute dehydration when the facility staff failed to monitor his fluid intake. The home was fined $10,000 – later reduced to $6,500 — by the Iowa Department of Inspections and Appeals.

Two weeks ago, DIA cited Glenwood for having placed residents in immediate jeopardy based on a failure to train and supervise the staff and a failure to follow physician orders related to a resident’s oxygen.

The center has a long history of care issues and is scheduled to close in 2024. It is run by the Iowa Department of Human Services, the same state agency that’s charged with protecting the health and welfare of children and dependent adults in Iowa.

The resident who died had a profound intellectual disability as well as cerebral palsy. He was hospitalized for eight days in November 2021 due to dehydration and a resulting acute kidney injury. Upon his return to the home, inspectors said, the staff repeatedly failed to provide the man with the prescribed amount of water each day. He died in February after being diagnosed with acute dehydration, a urinary tract infection and cardiac arrhythmia.

At the time, inspectors determined there was “a lack of training” at Glenwood to ensure the staff followed each resident’s care plan.

The more recent incident was investigated by state inspectors in late June, which led to a $7,750 fine and a conclusion that Glenwood had “failed to provide adequate and ongoing training and oversight to ensure staff competency.”

Those findings are tied to an incident in April, when a residential treatment worker entered the room of a 48-year-old male resident and noticed the man was gasping for air. The man’s skin was gray in color, his lips were blue, and his eyes were glassy, the worker later reported. The employee immediately notified two nurses who came to the room and discovered the resident’s supply of supplemental, bottled oxygen was switched off.

A review of video footage indicated the resident’s oxygen had been shut off three hours earlier and workers who subsequently checked on him had failed to notice.

According to inspectors, the footage shows the oxygen was shut off and disconnected at 12:22 p.m. when the man was moved from a common area to his bedroom. At 12:32 p.m., a nurse walked into the man’s room, suctioned his airway to prevent any blockage, and left two minutes later without noticing his oxygen supply  was turned off.

At 12:44 p.m., a worker walked into the room, was there for 10 seconds, and then left. At 2:20 p.m., two workers walked down the hallway and passed the man’s bedroom. At 2:38 p.m., a worker stood at the doorway and looked in at the man.

It wasn’t until 3:17 p.m. that the residential treatment worker entered the room, observed his condition and summoned the two nurses. The man’s oxygen-saturation levels had dipped to 62% — well under the 70% threshold that is considered life threatening.

Once the oxygen was switched on, the man’s vital signs improved, and his oxygen-saturation level increased to 100%.

Physician orders that were in place at the time of the incident called for the staff to visually check on the man every 15 minutes. An inspector interviewed one of the Glenwood workers who stated that she and a colleague worked on residents’ charts and on a puzzle until the afternoon-shift workers arrived. According to the inspector, the employee said she and her colleague had failed to check on the man “because they were being irresponsible.”

Both the Feb. 18 dehydration death and the April 13 oxygen-deprivation incident were investigated by DIA three months after they took place. The agency has acknowledged it is dealing with a significant backlog of complaints and self-reported incidents to investigate.

As of last month, there were 410 complaints pending against Iowa nursing homes that were at least 30 days old. Of those, 201 complaints – almost half the total number — were more than 120 days old. In fact, 24 of the pending complaints against Iowa nursing homes were more than one year old, according to DIA.

In January, the Glenwood Resource Center was fined $2,750 after 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 fined $2,750 for failing to employ sufficient staff to manage and supervise 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 over-reliance 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 of this year, Gov. Kim Reynolds announced plans to close Glenwood in 2024, having concluded that the DHS cannot meet the Department of Justice’s expectations for resident care.

Iowa Capital Dispatch is part of States Newsroom, a network of news bureaus supported by grants and a coalition of donors as a 501c(3) public charity. Iowa Capital Dispatch maintains editorial independence. Contact Editor Kathie Obradovich for questions: info@iowacapitaldispatch.com. Follow Iowa Capital Dispatch on Facebook and Twitter.

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site. Please see our republishing guidelines for use of photos and graphics.

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing. His 2004 series on prosecutorial misconduct in Iowa was named a finalist for the Pulitzer Prize for Investigative Reporting. From October 2018 through November 2019, Kauffman was an assistant ombudsman for the Iowa Office of Ombudsman, an agency that investigates citizens’ complaints of wrongdoing within state and local government agencies.

Iowans value integrity in their government. Free and independent journalism is what keeps our public servants accountable and responsive to the people. That’s why Iowa Capital Dispatch, a nonprofit, independent source for quality journalism, is working every day to keep you informed about what government officials are doing with your money, your freedom and your safety.

DEIJ Policy | Ethics Policy | Privacy Policy

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site.