A U.S. Department of Justice review of nine deaths at the Glenwood Resource Center in 2008 revealed no "systemic issues" related to the quality of care at the state’s largest facility for the mentally handicapped.
Despite the Department of Justice (DOJ) findings, the Iowa Department of Inspections and Appeals has levied a $11,500 fine against the facility for quality of care issues and staff failure to follow procedures relating to the "unexpected death" of a client at the facility which occurred after the DOJ review had been completed.
The recent fine brings the total to nearly $50,000 the facility has been levied over the last year.
The Glenwood Resource Center has over 900 employees and 300 clients.
The two-month long investigation was intended to reveal any "systemic issues bearing on the GRC’s compliance with general accepted professional standards of care." As part of the review, the medical records and all GRC findings of the clients who died were reviewed.
The DOJ report found that the nine deaths did not reveal "systemic issues regarding the care around the terminal event that contributed to the terminal event." In the case of the client death that occurred in November (after the DOJ review), an investigation determined that a nurse did not make a timely report to the physician regarding a client’s deteriorating condition which ultimately resulted in hospitalization. A report on that death stated "...had the facility responded in a more timely manner, the worsening condition that ultimately led to this person’s death might have been abated or stopped."
Kelly Brodie, interim superintendent of the Glenwood Resource Center, declined to name the client whose death resulted in the fine, but published reports have identified him as Timothy Alexander, 26, a five-year resident at GRC. The client was found unresponsive in his GRC living quarters less than 24 hours after a seizure and choking incident had required him to be hospitalized.
Brodie said the fine was related to staff not following the "accountability checks as required by his behavior support plan."
"I think the death was singled out because they (investigators) did find an issue - the staff were not responding to this individual's behavior support plan," she said.
The report indicated accountability checks were to be completed at 15-minute intervals for Client No. 1. Documentation showed that an individual staff member completed checks at 9 a.m. 9:15 a.m., 9:30 a.m., but could not document that a check was done at 9:45 a.m.
Emergency services were then summoned to the cottage at 10:03 a.m. when the client was found unresponsive in his room, said Brodie.
The client was taken to a Council Bluffs hospital where he died.
The GRC was fined $10,000 for the procedural error of failing to document the accountability check, Brodie said. The remaining $1,500 fine was related to the same client not receiving his medications after returning from outside medical services on the evening prior to his death.
"There's nothing in this report to indicate the failure to receive the medications the night before or potentially not doing the accountability check contributed to his death. These were more facility-level issues," Brodie said.
In addition to citing the point of care concerns at the GRC, the DOJ report went on to list issues related to preventative care, including delays in communicating and responding to changes in medical status, inaccurate medical records and missing health documentation.
There were a total of 12 deaths at the GRC center in 2008, a five-year high. All death investigations at the facility pass through multiple levels of peer and independent review before they are passed on to the Iowa Department of Human Services.
Brodie doesn’t consider the 12 deaths in 2008 to be an usually high number, citing the 11 deaths at the facility in 2006 and the majority of the client’s "fragile medical condition." Nearly half of the facility's 326 residents are diagnosed with profound mental retardation and have one or more medical conditions that place them at a high level of risk. More than one-third of the clients are over age 50.
"We have a very medically-fragile population here and that population is aging. I don't think we can say there is a normal number of deaths we can expect at any given time, but we have thoroughly reviewed these deaths, as have all of these other entities, and they have not identified any systemic issues," she said.
Consultant Judith Johnston, who formerly headed Alabama's state-run mental retardation facilities, was brought on earlier this month to help evaluate the Glenwood facility and make recommendations for improvement. Johnston will also work to help implement the DOJ’s standards for patient care.
"I think its been erroneously reported she was brought in to make recommendation regarding closing or consolidation of GRC and that is absolutely not her mission," said Brodie. "She is here to evaluate where we are and make recommendations for improving our services."
Brodie, who has served as interim superintendent since Tom Hoogestraat retired last fall, feels the facility has been operating under a dark cloud and a microscope during her short tenure.
"I think they (staff) continue to provide outstanding care for individuals, but yes I think this has impacted (staff) morale when they feel as though people are not fully understanding or in appreciation of what we do," she said.
Brodie said the only way to cure the concerns about the GRC and its future stability is improving public perception of the facility.
"We encourage people to come up and see what we do," said Brodie, who plans to take a contingent of legislators on a tour of the facility later this month. "We invite parents to come up when they come to visit their loved one and observe the care they are getting first hand.
"We want to be as transparent as possible and have people come up here and see the work and the care that is being provided so they can make a judgment about the quality of care."