Just a few months ago I wrote about several residents with diabetes who were not being properly monitored at Chestnut Manor nursing home in Herrin, Illinois. That pales in comparison to the report from the recent investigation. It’s only a matter of time before there are serious injuries or fatalities at Chestnut Manor.
A variety of new medication errors were found during a follow up survey of Chestnut Manor. In a jarring addition, staff at the nursing home were in conflict with administration as to what roles they played in the nursing home.
The nursing home inspector was told by the assistant administrator that a person was a Registered Nurse Consultant only to be told by that person that they were not fulfilling those duties, and that administration had been informed of that fact “about two weeks ago.” Duties for the position included acting as the medication trainer. When confronted, the administrator acknowledged receiving notice that the nurse would not be acting as Resident Nurse Consultant and stated “I guess I should have followed up on that.”
During the inspection, one resident was observed entering the unlocked medication room, pouring himself a small cup of medication and drinking it. Alarmed, the nursing home inspector verified that the contents were prescribed to the individual who had seen to his own medication. While this particular incident didn’t have tragic consequences, clearly residents who may be in the early or later stages of dementia cannot be given access to an unlocked medication room.
During the same inspection, the surveyor watched an unlicensed Chestnut Manor staff member administer three separate eye drops into the eye of one of the residents. The resident only had two eye drops prescribed. After a follow up investigation it was determined that the staff member had given one drop twice.
Another resident was observed being administered two oral medications. The resident had prescriptions for nasal sprays. At other times, pills that had fallen on the floor were administered, and staff members failed to use gloves while providing medications.
None of the medication errors witnessed at Chestnut Manor have ended in a wrongful death or other major injury yet, but that seems to be attributable to luck rather than any safety measures undertaken by Chestnut Manor. As an experienced nursing home lawyer, I witness conditions of neglect such as these that often lead to wrongful death lawsuits.