‘She was screaming in pain:’ Iowa nursing home cited for gangrene and death

A West Des Moines nursing home has been cited for the death of a woman who contracted gangrene and was left screaming in pain in the days before she was hospitalized, according to state reports.

State inspectors cited Promedica Skilled Nursing and Rehabilitation Center in March for 20 state and federal regulatory violations. The inspectors were at the home to investigate 23 separate complaints — an extraordinarily high number — pertaining to the home’s quality of care. Of those 23 complaints, 19 were substantiated by the inspectors.

Since last week, the care facility has been operating under a new name: Harmony West Des Moines. Prior to 2021, it was known as ManorCare Health Services of West Des Moines. The home is located at 5010 Grand Ridge Drive.

According to state inspectors, a relative of a female resident of Harmony West Des Moines was in the care facility on Feb. 13 and notified nurses that her family member was complaining of severe pain in her buttocks. The relative stayed with the resident for four hours, during which time the nurse allegedly failed to return to provide anything to relieve the woman’s pain.

The nurse later told inspectors she found the resident had sustained an anal fissure and reported that to the home’s advanced registered nurse practitioner. The nurse said the ARNP ordered ointment for the woman but never examined her.

The resident’s condition was not assessed in the nine days that followed, according to inspectors.

On Feb. 25, a licensed practical nurse notified the director of nursing that the woman was in pain with “bright red drainage” flowing from her buttocks. The staff called a physician and received an order for milk of magnesia to treat constipation.

Two days later, on Feb. 27, another licensed practical nurse at the home discovered the woman had very low blood pressure and there was bowel movement emerging from her vaginal area.

“She was screaming and you could hear her down the hall,” the nurse told inspectors. “She was saying her butt was on fire.”

The nurse said she telephoned the on-call doctor and left a message, waited for a response, and then called again. “It took an hour and a half before I got the order to send her to the ER,” the nurse told inspectors.

According to inspectors, hospital records show the woman was diagnosed with septic shock – a highly dangerous, widespread infection that can cause organ failure – as well as gangrene near her genitals, and a fissure, or opening, in the wall between her digestive tract and her genitalia.

The woman underwent surgery the next day and died on March 6.

‘I could hear mom screaming in pain.’

In a separate matter, the daughter of another female resident at Harmony West Des Moines told inspectors that on Feb. 11, her mother’s roommate had telephoned her at 2 a.m. to report that her mother “was screaming in pain and no one was helping her.”

The daughter said she went to the home at 6:30 a.m. that day and found her mother still “crying in pain and begging for help,” while saying, “My arm, my arm, oh my god, my arm hurts.”

“I could not touch her arm, she hurt so bad,” the daughter allegedly told inspectors.

Using her own phone, the daughter called her mother’s physician and then offered the phone to the male nurse who was on duty at Harmony West Des Moines. The nurse refused the phone, and allegedly told the daughter he didn’t have time that morning to give her mother her prescribed pain medication. “She was screaming ‘help me,’ and you could hear it up the hall,” the daughter told the nurse.

Three hours later, at 9:30 a.m., the pain medication had yet to be given and a volunteer offered to stay by the woman’s bedside so the daughter could go home. At 6 p.m., the resident’s roommate again called the daughter, who later told inspectors, “I could hear mom screaming in pain.”

The daughter called her mother’s physician who allegedly advised her to bypass the nursing home staff and call 911 to summon an ambulance.

Later, another daughter of the resident went to Harmony West Des Moines and discovered her mother was gone and the staff wouldn’t say where she had been taken. Eventually, the medical staff at Mercy West hospital contacted the two sisters and informed them their mother was being taken into emergency surgery as she had no pulse in her right arm and her hand was turning black. The hospital staff indicated they hoped they would not have to amputate their mother’s hand or arm.

The state inspectors’ records make no reference to the outcome of the surgery.

The physician who was contacted by the daughter and the volunteer on Feb. 11 later told inspectors, “You could hear her mom screaming out in pain in every phone call.”

Medical documents ‘destroyed’ by staff

In yet another incident that was investigated last month, state inspectors reported that a different resident of Harmony West Des Moines was taken to a hospital emergency room on March 3 suffering from abdominal pain and frequent vomiting. The resident was admitted with a diagnosis of septic shock.

In the days leading up to that hospital visit, a physician had ordered that the resident be seen by a gastro-intestinal physician. That appointment was never made, according to inspectors.

The director or nursing later told inspectors the staff at Harmony West Des Moines keeps what she called an “alert charting book” in which they documented residents’ issues on each shift so that the next shift would know which residents needed to be assessed.

“It is not an official document, so it is destroyed,” the director of nursing allegedly told inspectors.

The home’s administrator, Sammara Smith, could not be reached for comment Thursday.

The Iowa Department of Inspections and Appeals has cited Harmony West Des Moines for 20 violations of state and federal regulations, including failure to meet professional standards; failure to meet quality-of-care standards; failure to provide adequate tracheostomy care; failure to manage residents’ pain; failure to employ sufficient nursing staff; failure to maintain a medication error rate of less than 5%; and failure to provide adequate infection control.

The department has proposed two state fines totaling $19,000 against the facility. Those fines are being held in suspension while the federal Centers for Medicare and Medicaid Services considers imposing a federal fine.

In 2021, CMS fined the facility $30,000, which was later reduced by 35% to $19,500 because the home didn’t appeal the case. Last year, CMS fined the home $15,000, although that penalty was later reduced to $9,750 due to the lack of an appeal.

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