Iowa care facility cited for denying residents their pain medications

Jul 03, 2023

A Des Moines care facility with a history of care violations that includes maggot-infested wounds has been cited for repeatedly failing to give residents their narcotic pain medications.

According to a report from the Iowa Department of Inspections, Appeals and Licensing, Genesis Senior Living Center, 5608 SW Ninth St. has repeatedly failed to administer residents’ pain medications as ordered by a physician, posing an immediate threat to residents’ health and safety.

Four of the home’s 62 residents were not given their prescribed narcotic painkillers “for prolonged periods of time,” inspectors reported. Nurses and medication aides reported that because the drugs were often not available in the facility, the staff would initial the patient records and medication charts and then draw a circle around their initials — signaling to other workers that the drugs they were to administer weren’t actually being given.

One resident who had cancer of the larynx went eight days without receiving his three-times-a-day order of Percocet, an opioid pain medication. The man told inspectors he was fully aware he wasn’t receiving his prescribed painkillers because the facility didn’t have them in stock. “When asked if he was in pain during that time, his eyes widened and he nodded a definite yes,” the inspectors reported.

Three other residents, including one in hospice care, did not receive their prescribed fentanyl, a potent opioid commonly delivered via a patch applied to the skin. Over one 22-day period, the three residents with orders for fentanyl did not receive the drug for 11, 12 and 7 days, respectively.

One of those three residents told inspectors she was in pain, hurt everywhere, and rated her pain as a “9” on a scale of 1 to 10. Another of the three rated her pain as an “8,” and the inspector reported both women appeared to be in pain and were grimacing.

One of the home’s certified medication aides told inspectors that with regard to the home not having prescribed medications on hand, it happened more often than she cared to admit. The home’s director of nursing told inspectors she was looking into the shortage of fentanyl patches. But when asked by an inspector what she could say about the situation, the director of nursing remained silent and “just shook her head no,” according to the inspectors’ report.

A registered nurse allegedly indicated the problem was tied to the lack of a working fax machine for the previous six months, which complicated the process of ordering medications. Two nurses reportedly told the inspectors they didn’t think workers were diverting the narcotics for their own use and that the problem was more likely due to “sloppy nursing” or laziness on the part of the staff.

One worker told inspectors that when she assessed residents’ pain levels, she sometimes didn’t ask the residents and simply wrote down a zero if they appeared comfortable. She said one resident rated their pain at “8,” but said if she didn’t see any facial grimacing she would typically mark that down as a “2” instead.

As a result of the inspection, the facility was cited July 19 for 12 state and federal violations. DIAL proposed a $9,500 state fine, but held that fine in suspension to let federal officials determine whether a federal fine is warranted.

The state’s most recent previous visit to Genesis Senior Living Center was in April, when they went there to investigate a backlog of nine complaints, cited the owners for 15 violations, and held in suspension a proposed $15,750 state fine.

At that time, inspectors noted that residents of the home had complained the second-shift aides did little work, hid in closets and talked on their personal phones. After one resident complained to an aide about the length of time she had waited to have her undergarments changed, the aide allegedly threw a pair of briefs and a glove at her, saying, “F—ing change yourself,” and walked out. The aide was fired for the offense, according to the inspectors’ report.

The home was also cited for failing to address a resident’s bed sores, which worsened and then developed into a serious wound that resulted in exposed bone, a dangerous bone infection and a prolonged hospitalization. A nurse told inspectors that when she walked into the resident’s room, it “smelled like gangrene.”

The nurse told inspectors the lack of care provided for residents of Genesis Senior Living Center was the reason she no longer worked there, describing the level of care as “horrific.”

In December 2021, the state cited Genesis for 45 state and federal violations – an unusually high number. A nurse aide at the home told state inspectors that she had found open sores on a male resident’s legs that were dripping with fluid and maggots, telling inspectors, “It was horrible!”

According to the inspectors’ reports, the aide said that when she removed the man’s socks, “maggots fell out of his heel, and they were coming out of the sores on his legs.” The man complained of a burning sensation in his legs. A nurse was summoned and was so upset she took photos of the man’s legs before having the man transported to a local hospital by paramedics, the aide told inspectors.

According to the inspectors, the care facility staff reported the man “had sores and maggots on his right leg at the top of the calf, right shin, left shin, and the majority of maggots came out of his left heel. The maggots were in various colors — brown, white, and tan. There were dead ones, live ones, little ones and big ones.”

The man had been admitted to the home in July 2021 and, according to inspectors, the home’s subsequent failure to provide adequate care over the next 10 weeks led to him being hospitalized on three separate occasions for conditions that included maggots in his wounds, a urinary tract infection and sepsis. The man died on Sept. 30, 2021, one week after his third and final transfer to a hospital.

Genesis Senior Living Center’s current administrator, Tami Little, did not return a call seeking comment. The home is owned by DSM Healthcare Management, a for-profit company owned in part by Judah Bienstock of MGM Healthcare, a St. Louis company that manages seven Iowa nursing homes and 18 facilities in Missouri and Oklahoma.

Find this story at Iowa Capital Dispatch, 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: [email protected].