The nursing home resident’s death by suffocation was not investigated by state regulators

The state of Iowa has never investigated the death of a nursing home resident that was attributed to worker misconduct.

Earlier this week, the Iowa Capital Dispatch reported that an administrative judge ruled in October that an employee at Des Moines’ Trinity Center at the Luther Park nursing home contributed to the death of a resident by choking in July by ignoring orders from his boss.

The Capital Dispatch asked the Iowa Department of Inspections and Appeals, which oversees nursing homes, why the death was not mentioned in the published reports resulting from inspections of the home in August and October.

DIA spokeswoman Stefanie Bond said late Tuesday that the death was not self-reported to DIA by Trinity Center, as required by Iowa law. In addition, she said, the agency’s health facilities division had not filed any complaints about the death. She said DIA inspectors are now investigating the matter.

The DIA’s Health Facilities Division, which is responsible for inspecting nursing facilities, is separate from the Administrative Hearings Division of the division that handled the worker misconduct case that brought to light the resident’s death.

Resident choked on food and died

State unemployment records show that Richard A. Kerr was working as a cook at Trinity Center in July when two new residents were admitted. Kerr, who did not have access to residents’ medical records, was not trained or authorized to create menus for residents and was ordered not to do so for the two newly admitted residents.

Kerr allegedly created the menus anyway, creating a “meal menu” for a resident that indicates the person can have a regular or unrestricted diet. This resident’s medical regimen restricted her diet to soft, bite-sized pieces of food.

As a result of the alleged error, the resident was given pulled meat instead of minced meat. The resident choked on the flesh, was taken to a hospital, and died. Kerr was fired a few days later.

According to the findings of the judge presiding over a DIA hearing on Kerr’s application for unemployment benefits, Kerr committed workplace misconduct that contributed to the death.

In her ruling, Administrative Judge Carly Smith noted that Kerr “had been made aware that it was dangerous for him to enter the meal cards unless he was properly trained because it could have detrimental effects on residents, e.g. B. suffocation”. She wrote that “as a result of[Kerr’s]failure to follow directions, one resident choked on the food, was hospitalized, and died.”

Per Smith’s decision, Trinity Center had previously warned Kerr against creating resident menus. In February 2022, he had changed menus for some of the residents, causing his boss to change them back again to match doctors’ orders.

After that incident, Kerr’s supervisor reportedly reminded him that he lacked the training and authority to specify food for residents, and she reportedly warned him of the potentially deadly risks involved.

Records of the death are sought

Earlier this week, the Capital Dispatch DIA asked for access to the six exhibits in Kerr’s unemployment case. Bond said that although DIA handled the case, the request for documents should be directed to Iowa Workforce Development, where such records are kept.

An Iowa workforce development attorney, Rebecca Stonawski, responded to the request by saying that Capital Dispatch must provide a signed “waiver” from Kerr or Trinity Center authorizing the release of the documents.

The Capital Dispatch disagreed, noting that the exhibits are a public record when an unemployment case advances to the level of an administrative hearing before a judge.

Stonawski then said IWD would “like to search for the documents” and estimated the cost of finding them at between $20 and $50. She added that “team members from IWD are on the road this week” and that the agency will contact the news organization again once the recordings are located.

The Capital Dispatch then asked for a breakdown of IWD’s expenses in searching the records, noting that news reporters have historically been able to locate specific case exhibitions in under 60 seconds using a dedicated public-access terminal used.

Stolawski has not yet responded.

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