Despite court monitoring, three residents sustain broken bones at troubled Humboldt care facility

Three residents of a bankrupt Iowa nursing home have suffered broken bones in recent months, despite monitoring by a court-appointed patient care ombudsman.

The injuries have triggered $30,000 in potential fines.

The QHC Humboldt North in north-central Iowa filed for bankruptcy in January as part of the QHC Facilities chain of nursing homes. The chain is currently in the process of being sold to a new owner, Blue Diamond Equities, also known as Blue Care Homes.

According to state inspectors, one of QHC Humboldt North’s 47 residents suffered a broken femur after a fall on June 6; another suffered a broken shoulder on Aug. 9 and a fractured clavicle on Sept. 4; and a third suffered a fractured hip on July 24.

In the first two cases, the falls were alleged to be the result of workers improperly using, or failing to use, devices intended to help residents move from a standing to a sitting position. In the third case, the staff was unaware of the resident falling and was unable to determine how the man’s hip was broken. The man told inspectors that he fell out of his chair. An employee told inspectors the man didn’t really fall but slid forward and became caught in the gap between the chair and its raised footrest.

Hours after the fall, an employee told a nurse the man was complaining of pain, and the nurse allegedly responded by saying the man “does this all the time” and failed to go to the man’s room to check on him.

The state has proposed a $30,000 fine against QHC Humboldt North, but held that fine in suspension while the federal Centers for Medicare and Medicaid Services determines whether a federal fine is warranted instead.

In March, CMS imposed a $15,000 against the home after the facility was cited for medication errors and inadequate infection control.

Ombudsman oversees care for $375 an hour

Nine months ago, shortly after QHC Facilities filed for bankruptcy, a federal judge appointed Susan Goodman, a lawyer and registered nurse from Arizona, to act as a patient care ombudsman and monitor the care being delivered at the QHC homes. Since then, Goodman has filed regular reports with the court – most recently on Sept. 9.

None of Goodman’s reports to the court make any mention of the injuries suffered by residents on June 6, July 24, Aug. 9 and Sept. 4.

Goodman’s report in May noted that the new management company operating the home “did not bring immediate operational resources relative to continued staffing challenges.”

In her July report, Goodman told the court “no staffing concerns were noted” but added that the “administrator was transparent in conveying that staffing challenges had arisen recently with the administrative assistant engaging to call-in additional staffing support when needed.” She said the facility was “more stressed” than it had been during her previous visit but did not elaborate.

In her Sept. 9 three-page report, Goodman told the court that 14 of the home’s 47 residents were positive for COVID-19. She stated that aside from the COVID-19 outbreak, “the most significant news at this location relates to turnover in the director of nursing role,” noting that in the previous few months three different individuals had served in that job and the home was currently attempting to recruit someone into the position.

Goodman told the court the “larger challenge” at Humboldt North is its ongoing reliance on workers from temporary staffing agencies rather than directly employed caregivers.

“Fortunately,” Goodman reported, “Humboldt North was able to hire a part-time nurse consultant who previously worked for the Iowa Department of Inspections and Appeals,” referring to the state agency that currently oversees QHC Humboldt North and all other Iowa nursing homes.

Goodman declined to comment on her reports to the court, telling the Iowa Capital Dispatch, “I never talk to the press in my role as an ombudsman.”

In an affidavit supporting her appointment as QHC’s patient care ombudsman, Goodman stated her regular billing rate was $375 per hour.

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