IDPH has cited and fined Bella Terra nursing home in Wheeling after a resident there received the diabetes medication for his roommate, resulting in an intensive care admission for severe hypoglycemia.
One of the basic tasks that nurses have is passing medications. When they pass medications, nurses are trained to follow the 5 rights: (1) right patient, (2) right medication, (3) right dose, (4) right route, and (5) right time. To complete these checks, they need to concentrate when they work and work without distraction.
The resident at issue was not a diabetic, but his roommate was. One of the medications he was receiving regularly was Glipizide. Glipizide has the effect of stimulating the pancreas to produce insulin which in turn drives down the blood sugar levels. Low blood sugar levels results in a condition called hypoglycemia. Severe hypoglycemia is a medical emergency and can cause significant injury to the brain if not corrected.
On the day that the resident was admitted to the hospital, the staff noticed that the resident was sluggish and non-responsive. They checked his blood sugar levels and found that they were at 30. They notified the doctor of the change in condition who ordered glucagon which was intended to restore his blood sugars to normal levels. When the resident’s blood sugar levels dropped again, he was sent to the emergency room.
In the emergency room, they ran a drug screen on him which showed that he had been administered Glipizide. Further investigation revealed that this was a medication which was supposed to be administered to his roommate. The nurse who was responsible for administering the medications was suspended and then terminated. The nursing home reported to the state that she had been observed pre-pouring medications and then writing room numbers on the cup and then talking on her phone while doing medication pass. This is something that would be a source of distraction during the medication pass.
This was obviously a highly preventable nursing home medication error brought about by failing to verify that the medication was being given to the proper resident. Staff training and enforcement of safe medication pass practices is really what was required to prevent this from occurring. However, that requires investment in the staff. Failing to invest in staff training is a feature of the nursing home business model. 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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