IDPH has cited and fined Villa Health Care East nursing home in Sherman after a resident was given the medications ordered for a different resident.
One of the basic functions of a nurse at a nursing home is to do medication pass. Before actually dispensing the medication, one of the basic checks that a nurse must make is that they are giving the medication to the right resident. To help assure that this is being done, many nursing homes have photos of the resident on the Medication Administration Record that is on the medication cart. Additionally, the nurse is required to actually verify that the resident is the one that the medication for whom the medication has been ordered. Giving a medication to the wrong resident carries with it the potential for disaster because of what can occur when the resident receives someone else’s medications and from the delay in receiving or failure to receive their own.
There was no issue that a medication error happened in this case. Rather than push the medication cart down the hall and stop outside each room, the nurse responsible for the medication error out the medications into the dispensing cup at the nurse’s station and walked down the hall to give the medication to the resident for whom the medications were ordered. Along the way, she stopped to talk to another resident. That discussion distracted the nurse, and she then entered the wrong resident’s room and gave her someone else’s medications. The nurse later explained that the discussion with the one resident in the hallway probably caused her to forget what she was doing and that because she was new and did not work that particular hallway, she did not know the residents well enough to know who was supposed to be getting what medications. As a result of this medication error, the resident received blood pressure medications and insulin that was intended for another resident.
The nurse recognized the medication error later that shift and notified the resident’s doctor. The doctor advised the staff to monitor vital signs every 15 minutes and when the resident’s blood pressure dropped and her heart rate dropped, orders were given to send the resident to the emergency room. On arrival, she was transferred to the intensive care unit and was hospitalized for 5 days before she was stable enough to return to the nursing home.
One of the interesting tidbits found in the citation is that there was no actual documentation of the medication error in the resident’s medical chart. The practice at that facility was to document incidents as this outside the nursing home chart. There are a number of cases which we have handled where crucial information regarding choking accidents, nursing home falls, or bed sores were not properly documented in the resident chart and had to be obtained after the lawsuit was filed. Having someone on board who knows what to ask for is one of the advantages of hiring an experienced nursing home lawyer.
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 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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