Care facility resident dies after being found soaked in blood

A resident of a Williamsburg care facility died after a nine-hour delay in receiving medical care for multiple serious injuries she sustained in a fall, according to state officials.

State inspection reports indicate that at 9:45 p.m. on June 2, 2023, a nurse aide at the Highland Ridge Care Center in Williamsburg found a female resident on the floor of her room complaining of pain “all over.” The aide later told inspectors she would not forget the scene as it was so traumatic, with the resident writhing on the floor in blood-soaked pajamas.

According to the inspectors’ report, the aide said there was blood on the floor, on the walls, in the woman’s hair, on her hands and legs, and on the left side of her head. There was so much blood, the aide reportedly told inspectors, that she began wiping the resident’s hands with a washcloth in an effort to find the source.

The Highland Ridge staff allegedly checked the woman’s neurological signs, then showered her and placed her in bed with no medication for pain. According to state records, a worker at the home later told inspectors they had to shower the woman “because there was so much blood they couldn’t find where it was coming from.”

An aide who worked the overnight shift later told inspectors that after being put to bed the woman lay in the fetal position “shaking really badly.”

The registered nurse who worked at the home that night contradicted those accounts and told inspectors that immediately after the fall the resident enjoyed full range of motion in both arms and both legs and had no complaints of pain.

At 6:30 a.m. the day after the fall, the resident was complaining of pain in her right arm and cried out when a nurse touched her. The woman was transported to a hospital emergency room where the staff noted her right leg was shortened and rotated outward, and that she had a head laceration with dried blood above her right eye. A series of X-rays revealed a displaced fracture of the right arm, as well as a fractured leg and hip.

The resident was then transferred to a larger hospital for a higher level of care where, according to state inspectors, the staff said the woman had sustained “significant bleeding from the head (and) two staff reportedly got her off the floor, showered her, and placed her in the bed for the night without calling the physician or family.”

State records indicate a family member of the resident complained to inspectors that the staff at Highland Ridge had left their relative “to suffer in pain all that night with a fractured hip and shoulder.”

Ten days after the fall, on June 12, the resident died.

The Iowa Department of Inspections, Appeals and Licensing has proposed a $9,000 fine against the facility for failing to provide appropriate pain management, an additional $9,000 fine for failing to assess and address a resident’s altered condition, and an $8,000 fine for failing to ensure residents remain free of neglect or abuse.

Those proposed state fines are being held in suspension while the Centers for Medicare and Medicaid Services considers the imposition of federal penalties.

The 59-bed care facility currently has CMS’ highest overall rating, five stars, for quality of care. No federal penalties have been imposed at Highland Ridge in the past three years, according to CMS, and state records indicate the home was last issued a fine and citation in 2013.

The Iowa Capital Dispatch was not able to reach the home’s administrator for comment Friday.