Care Initiatives Fined

The Iowa Capital Dispatch recorded the meager fine paid by a nursing home for killing a resident. The nursing home, Odebolt Speciality Care in Sac County, Iowa, was fined only $8,500 as a result of a resident’s wrongful and preventable death. Based on the inspector’s report, workers of the facility noticed the woman unresponsive with an empty oxygen tank when going to take her to lunch. The resident suffered with congestive heart failure and required supplemental oxygen.

Reports state that the woman’s oxygen saturation level ranged from 12% to 45%. The woman was immediately transported to a nearby hospital, where she was diagnosed with an anoxic brain injury. After air transportation to a larger hospital, the woman died a few days after admission. 

Odebolt Specialty Care is owned and operated by the West Des Moines nursing home chain Care Initiatives. The facility failed to replace a resident’s depleted oxygen tank causing the vulnerable woman’s death. 

The inspections department allegedly stated that the staff repeatedly failed to monitor the resident’s vital signs and failed to check her oxygen tank to make sure she could breathe properly. The clinical records from Odebolt Specialty Care show the staff failed to check and record the woman’s oxygens levels in the days leading up to her incident. During this period, the woman experienced erratic behavior, odd facial expressions, and signs of lethargy.

The director of nursing told inspectors that she expected the staff to ensure that the oxygen supply was functioning, but she “didn’t know for sure what kind of education” staff members had on this device. Two nursing assistants allegedly told inspectors they do not remember any education or training on a resident’s use of oxygen concentrators and tanks. 

State inspectors cited Odebolt Specialty Care for failing to assess and treat a wound on another resident’s leg multiple times. This later resulted in the wound growing or “tunneling” into her flesh. A nurse practitioner from a local hospital told inspectors that the wound was “horrible.” The woman had been admitted to the facility with a wound vacuum and specific instructions. However, the nurse practitioner allegedly said that she knew no one at the facility had changed the dressing as it still had its original date markings. Inspectors concluded that the dressing had been changed twice, once on the day of admission and the day of her discharge. There is no further information regarding the resident’s survival or hospitalization. 

Still, it is unclear why the investigation of the incident in May 2023 took place seven months later. Records state that when the inspectors visited the facility in December, they were responding to a backlog of four separate complaints.