A 30-year-old resident of the state-run Glenwood Resource Center for individuals with disabilities died of acute dehydration after facility staff failed to monitor his fluid intake, state inspectors allege.
The center, which has a long history of care issues and is scheduled to close in 2024, has been fined $10,000 by the Iowa Department of Inspections and Appeals.
According to state records, 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 discharge, the resident’s doctored order the man to receive a minimum of 2,000 milliliters of fluid – about 68 ounces — per day while at Glenwood.
On Jan. 10, the order was increased to 3,000 milliliters, or 101 ounces, per day, with the understanding that if the goal was not met, a nurse would be notified so fluids could be provided through a tube.
The resident’s medical records indicate the resident received less than the prescribed 3,000 milliliters on nine of 15 days in February, with no supplemental fluids provided via tube as planned.
On Feb. 16, a worker at the center ordered a set of labs to be taken to evaluate the man for possible acute dehydration, a urinary tract infection and cardiac arrhythmia, then had the resident taken by ambulance to a hospital. Two days later, the man died at the hospital after being diagnosed with severe hypernatremia — a high concentration of sodium in the blood – and acute kidney failure and a urinary tract infection, all of which can result from acute dehydration.
Inspectors determined there was “a lack of training” at Glenwood to ensure the staff looked to the proper documents to determine a residents’ care plan and then followed through on that plan.
In January, Glenwood was fined $2,750 after an incident in which a worked 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.”
Court records indicate a former Glenwood superintendent, Jerry Rea, authorized and conducted research experiments on residents involving sexual arousal and that he did so without the residents’ permission. Rea was fired in late 2019. The records were tied to lawsuits filed by former staffers of both the Iowa Department of Human Services and Glenwood.
In April, Gov. Kim Reynolds announced plans to close Glenwood in 2024, having concluded that the state cannot meet the DOJ’s expectations for resident services.
“Iowans with intellectual and developmental disabilities deserve quality care that aligns with the expectations of the DOJ,” Reynolds said in April. “Our best path forward to achieve those standards is closing GRC and reinvesting in a community-based care continuum that offers a broad array of services.”
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