A troubled Iowa center for people with intellectual and developmental disabilities failed to monitor the fluid intake of a 30-year-old resident who died in February due to dehydration, state inspectors said in a report.

The Iowa Department of Inspections and Appeals has fined the Glenwood Resource Center $10,000 after inspectors found that center staff failed to ensure that the man received at least 101 ounces (3,000 milliliters) of fluids every day, as ordered by his doctor.

The man — who had profound intellectual disabilities and cerebral palsy, among other conditions — was hospitalized for eight days in November for dehydration and a resulting kidney injury, according to the report filed May 24. The doctor’s order included a directive for the staff to call a nurse to give him additional fluid through an abdominal tube if he did not drink the minimum daily amount.

The man was taken back to the hospital on Feb. 16 after a nurse at the center noted his mental status had changed, and he was lethargic, had high blood pressure and was experiencing “increased jerky movements.” A nurse practitioner noted his “lips were dry.”

Two days later, the man died at the hospital. He had a severely high concentration of sodium in the blood, kidney failure and a urinary tract infection, all of which are results of acute dehydration, according to the report. It also noted the amounts of fluids the man was listed as ingesting on his daily activity record at the center and the lab results from the hospital “did not add up.”

“Review of the fluid totals entered by staff revealed (the client) failed to reach the goal of 3,000 milliliters on 9 out of 15 recorded days in February,” the report said. The report blamed a lack of staff training for the failures.

The Glenwood center on Friday referred questions to the Iowa Department of Human Services, which did not immediately answer questions — including about whether any center staff faced discipline, termination or criminal investigation related to the resident’s death.

It’s the latest in a string of troubles at the center. In April, Gov. Kim Reynolds announced the center will close by June 30, 2024. That came months after the U.S. Department of Justice issued a strong condemnation of the way Iowa treats people with intellectual and developmental disabilities.

In a December 2020 report, federal officials said the Glenwood center likely violated the constitutional rights of residents by subjecting them to human experiments, some of them dangerous.

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