BELLEVUE, Iowa — A Bellevue nursing home has been cited by state and federal authorities for medical errors that possibly contributed to a death and left several residents in pain and others at risk of severe medication interactions.

The Iowa Department of Inspections and Appeals fined Mill Valley Care Center $8,500, which is being held in suspension until the Centers for Medicare and Medicaid Services decide whether to collect a federal civil money penalty for the violations, according to Stefanie Bond, DIA communications director.

Mill Valley Administrator Brandy Dierks assumed her leadership role two weeks ago. She said she does not know to what extent leadership at the nursing home was aware of the conditions at Mill Valley prior to the investigation.

“Ensuring the safety and well-being of our residents is our top priority, and we take any (alleged) violation very seriously,” she said in a statement. “As a nursing facility, we are required to self-report any incidents to CMS and DIA that lead to major injuries, hospitalizations or death and have worked with DIA, our staff and residents to address all inspection findings.”

According to inspection records, the incidents in question stemmed from two complaints, which are considered confidential. Investigators reviewed the allegations from March 10 through April 14.

The most serious offense — which, left unaddressed, could have placed the 54-bed facility in “immediate jeopardy” of losing its CMS provider agreement — occurred when staff failed to clinically assess a resident with a known heart condition and history of heart surgery after his health deteriorated. They did not notify the man’s cardiologist of the change in his condition.

Staff also improperly discontinued one of his heart medications without notifying his cardiologist, possibly contributing to his death about two weeks later, the doctor said.

In the period up until his death on March 6, the resident called 911 twice, stating staff would not help him. The second call, received on March 3, “revealed an obvious decline in the resident’s condition … with shortness of breath and weakness evident by the resident’s voice,” according to investigators.

Meanwhile, the resident frequently posted on social media on March 4 that he was struggling to eat, use the restroom or breathe. He requested help multiple times.

Employees reported to inspectors that some staff did not want to “deal with the resident or go into his room” because he frequently yelled, refused treatment and ordered them out of his room. Some feared he might become “physical.”

The resident’s power of attorney said they received a phone call from the facility’s former administrator and nursing director, who asked the POA to disable the resident’s social media account and retrieve his cellphone, which “caused problems.”

On March 2, staff began to administer an antacid medication to help the resident’s indigestion, but inspectors could find no record of a clinical assessment nor need for the medication. Up until the resident’s death, he continued to complain of heartburn.

Once inspectors notified administrators that the incident placed the facility in “immediate jeopardy,” all nursing staff were educated on cardiac assessments, signs and symptoms of cardiac complications, double-checking physician orders and notification procedures.

The inspection report also revealed additional medical errors.

Three residents experienced ongoing severe pain, for which they were administered fentanyl patches every three days along with narcotics administered orally each day and as needed.

Investigators determined staff repeatedly failed to apply the patches to the residents as scheduled and that the facility repeatedly ran out of them along with pain pills, leaving residents without some of their pain medications for as many as three days at a time.

Staff reported that one resident “was crying, had facial grimacing and was in obvious pain” when that occurred.

Investigators determined that staff did not notify the pharmacy of low or exhausted supplies until it was too late for pharmacists to obtain physician refills on the same day.

Inspectors documented additional medication woes at Mill Valley.

In early April, physician orders directed staff to give both a blood-thinning medication and an antifungal medication to two residents. Both times, staff were alerted by an electronic record system that administering both medications could cause a severe interaction.

The antifungal medication was nonetheless administered for almost a week.

Investigators found that the order for the antifungal medication did not originate with the facility’s physician, who was on vacation, but rather from standing orders from the facility’s medical director that authorized nurses to dispense medication without physician review.

Both residents’ records lacked documentation of an assessment of their skin conditions, of an indication as to why the medication was required or that the potential for severe interaction had been reviewed by a physician.

Facility administrators recently submitted a corrective plan to DIA and CMS, which included a review with nursing staff of the facility’s medication reordering procedure and directing the night shift nurse to monitor supplies.

The facility also will cease to use standing orders and will notify prescribers of potential drug interactions.

The two complaints concerning Mill Valley were the first to be submitted to the DIA since 2019. Prior to that, five were lodged from 2009 through 2011, but only two were substantiated by investigators.