State officials have acknowledged that a resident of the state-run Clarinda Mental Health Institute died after eating food he should not have been served. A report issued today by the Department of Inspections and Appeals (DIA) shows staff at the facility, on September 1, gave a peanut butter sandwich to a patient who was only to be given pureed food.

The patient was later found unresponsive at a dining table, having choked to death. Amy Lorentzen McCoy is a spokesperson for the Department of Human Services, which runs the home. “We determined, and the DIA report shows, that policies were not followed on September 1. We have taken action to strengthen those policies,” McCoy says. The DIA has approved the policy changes, which include the “retraining of nursing staff on dietary card use and adherence to policy.”

A state fine of $10,000 was proposed, but was recently dropped as a fine is being levied by a federal agency. McCoy says the DHS was notified by the Centers for Medicare and Medicaid Services that there will be a civil money penalty of $8,250. A release from the DHS indicates, as result of the resident’s death, “appropriate personnel action has been taken up to and including termination.”

McCoy said she could not discuss those details any further. According to the DIA report, a dietician at the Clarinda Mental Health Institute said it was 100 degrees in the facility’s kitchen on September 1, so she decided sack lunches rather than a cooked dinner would be served for the residents’ evening meal. While some of the lunches included pureed food, the bags were not “tagged” by staff so each resident got their own prescribed meal.

The Clarinda Mental Health Institute is one of Iowa’s four mental health institutes, providing short-term psychiatric treatment and care for severe symptoms of mental illness. Clarinda has 15 adult psychiatric beds and 20 gero-psychiatric beds.

Here are the documents relating to this case:

MHI Citation

MHI Report