IDPH has cited and fined Gardenview Manor nursing home in Danville after a resident there ended up in intensive care due to being given another resident’s medications.
One of the basic functions that a nurse carries out day to day in a nursing home is passing of medications. When a nurse passes medications, there are supposed to be multiple checks that are made – is this the right patient? Is this the right medication? Is this the right dose? Is this the right dose? Is this the right time? The medication is not supposed to be given without those checks being made.
Of all of these, perhaps the most important of these is making sure that the medication is being given to the right patient. If the medication is given to the wrong person this has the potential for disaster. To help combat the potential for error, some nursing homes actually have the picture of the resident on the container for the medication. Nonetheless, these kinds of nursing home medication errors do occur, and can have significant medical consequences.
In this incident, one resident was given a set of medications that were intended for another resident. The citation from IDPH didn’t spell out why the medication error occurred, but it was clear that the resident was given someone else’s medications. These included: Clonidine, Coreg, Losartin, Hydralazine, Coumadin, Nepro, Vitamin C, Phosio, Calcium Carbonate and Vitmain D3.
To their credit, the nursing home staff promptly recognized the error and took reasonable steps in reaction to that. They notified the resident’s doctor, they contacted poison control, and closely monitored the resident. When the resident’s blood pressure began to drop, they called for an ambulance and had the resident transported to the hospital where he was placed in the intensive care unit as part of a 5-day hospital admission.
The real question of course is why this medication error occurred. The citation doesn’t address that, but having the critical safety measures that are part of passing medications become “routine” is probably a part of the problem. The other likely root cause would be understaffing of the nursing home which may have resulted in the nurse being rushed or distracted during medication pass. Understaffing of a nursing home is one of the features 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 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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