An Iowa nursing home inadvertently locked a resident out of the facility, leaving her outside the building overnight in the rain.

According to state inspection records, a female resident of the Harmony Marshalltown nursing home exited the facility at 8 p.m. on July 7, to sit in the home’s courtyard. The resident couldn’t get back into the facility until 6 a.m. the following day.

Inspectors allege the staff failed to do visual bed checks on the woman for 10 hours, leaving her pounding on the door of the building amid rain, thunder and lightning.

The woman “began to panic, became fearful, scared and crying,” inspectors allege. Eventually, a kitchen worker heard her pounding on the door and let her inside. The woman later told inspectors she would no longer go outside alone to smoke for fear of it happening again.

The woman “experienced serious actual psychosocial harm due to being left outside overnight,” the inspectors reported.

Inspectors concluded that while the courtyard door’s locking mechanism wasn’t engaged, the latch and the weight of the door effectively locked out anyone not strong enough to open it. The door “failed to open without excess force,” the inspectors concluded, which resulted in “in a serious likelihood of serious injury, impairment or death.”

The woman later told inspectors she had been had been scared and cold. She reported that she kept pushing on a doorbell to summon the staff but later learned the device was broken and didn’t work. She reported that she sat by the gas grill in the courtyard but didn’t want to touch it due to the lightning.

“She just tried to huddle against the door to keep warm,” the inspectors reported.

The kitchen employee who let the woman inside later told inspectors the woman was crying and shaking from being wet, scared and cold. A colleague described the woman as hysterical. A licensed practical nurse told inspectors the woman was “emotionally and psychosocially devastated” about being left outside all night.

Man was left with ‘nowhere to go’

Harmony Marshalltown was also cited for an incident involving a male resident of the home who left the facility on July 3 at 6 p.m. to visit his dog at a friend’s home. The man didn’t inform the staff he was leaving, according to inspectors.

At around 8:50 p.m., the administrator of the home became aware the staff couldn’t find the resident, so she and the director of nursing left the building to go look for the man.

At around 10 p.m., the administrator notified the police the man was missing. She and the director of nursing then continued their search until 1:30 a.m.

At about 2 a.m., the resident called Harmony Marshalltown to request a ride back to the facility from his brother’s house — although state records also refer to the house as belonging to a friend.

After no one from the facility showed up, the resident left his brother’s house and, at 5:30 a.m., was found at a gas station where the police provided assistance and summoned the administrator of the home.

At the convenience store, the administrator allegedly attempted to have the resident sign a form indicating he was discharging himself from the facility against the staff’s medical advice. The resident later told inspectors that because he was so angry about the situation, he signed the paperwork, after which the administrator left the store.

The inspectors allege the resident then drove his motorized wheelchair around town for a few hours, “scared, fearful and upset that he had nowhere to go.” At about 9:30 a.m. he returned to the home and was readmitted at his request.

According to the report of the state inspectors, they asked the administrator of Harmony Marshalltown about the staff’s failure to respond to the resident’s request for a ride. The inspectors allege the administrator responded that “she and the director of nursing were exhausted.” The administrator allegedly told the inspectors something to the effect of, “Excuse me if I went to bed (and) let the police handle the situation.”

The administrator reportedly added that she didn’t hear her phone when a worker called later to report the resident was at his brother’s house in need of a ride.

During her interview with inspectors, the administrator reportedly became “very upset” and, according to the inspectors, said, “Well, the facility didn’t have transportation to bring him back at that time of the morning and what were we supposed to do?”

According to the inspectors’ report, someone with the home’s corporate staff agreed the facility could have handled the incident better and had someone bring the man back to the home when he sought assistance.

The Iowa Department of Inspections, Appeals and Licensing proposed three fines against Harmony Marshalltown totaling $19,000. The fines have been held in suspension while the Centers for Medicare and Medicaid Services determines whether a federal fine is warranted.

The administrator of the home, Grace Maitland, was not at Harmony Marshalltown on Friday and could not be reached for comment.