IDPH has cited and fined Bridge Care Suites nursing home in Springfield after a resident there had to be admitted to the intensive care unit after staff there failed to administer her diabetes medications.
The resident at issue was admitted to the facility late in the afternoon with orders to get three medications to treat her diabetes: 1) Lantus (a long acting insulin) at bedtime, 2) Humulin, given on a sliding scale, before meals and at bedtime, and 3) Lispro, before breakfast, lunch, and dinner. At the time that she was admitted to the facility, she was alert and oriented. None of the diabetes medications were given on the day of admission. The reason stated in the chart was that the medications had not yet arrived from the pharmacy. Her bed time glucose reading was 124.
The next morning, her glucose level was not checked on time because the nurse could not find a working glucometer. It did get checked, late, at 7:30 a.m. and was at 568. The resident was described then as being awake but drowsy. The resident did not receive her morning medications. At 10:30 a.m., her blood sugar levels read 517. The resident was sent to the hospital around lunchtime where the resident’s family reported that she was more confused than normal, and the lab work-up showed that she was suffering from diabetic ketoacidosis. Diabetic ketoacidosis is a result of your body not producing enough insulin. Some of the potential complications associated with diabetic ketoacidosis include swelling of the brain, kidney failure, and respiratory distress. The resident was admitted to the intensive care unit.
At first blush, this would seem to be am issue where there may be some shared liability between the pharmacy and the nursing home for this medication error, but further investigation revealed that it was really a training issue. The nursing home had an automated backup medication dispensing system. If the resident needed medications that were not on hand or medications were needed on an emergency basis, the nurses could reach out to the pharmacy and get a code which when entered would result in the medication being dispensed. The medications that this resident needed were available through the backup dispensing system. The nurse charged with caring for this resident did not know about this system and did not ask other nurses on the floor about what to do, did not contact a supervisor about what to do, and failed to notify the resident’s doctor about the unavailability of the medication. Further, the nurse did not notify the doctor’s office right away about the 568 reading at 7:30 a.m. which is a critically high reading.
Making all of this worse is the fact that the resident also experienced a nursing home fall that day. One of the things that happens after a resident experiences a nursing home fall is that the undergo a 72-hour fall watch which includes performing serial neuro checks to evaluate whether a resident suffered from a brain bleed after the nursing home fall. This means that the resident’s declining mental condition should have been front and center for the nurse on duty.
One of the basic things that nurses are responsible for is giving residents their physician-ordered medications. The nursing home here a system in place to deal with the possibility that necessary medications might not be delivered by the pharmacy, but failed to train the nurse on duty as to the fact that it was available or how to use it. This is a failure which comes from a lack of resources devoted to staff training which is as much a feature of the nursing home business model as understaffing of the nursing home. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
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