IDPH has cited and fined Palm Terrace nursing home in Mattoon after a medication error resulted in the hospitalization of a resident there.
One of the basic tasks that a nurse does in a nursing home is pass medications. Generally, the “med pass” is done by the nurse stocking a medication cart with the medications to be given to the residents under their care. To make sure that the medication is delivered to the intended resident, nurses are required to do a series of “right” checks before actually giving the medication.
Failing to give medication to the intended resident can be a complete disaster. It means that the resident receiving the medication will be receiving medication that is not intended for them, may be entirely unsuitable for them, may have drug interactions with other medications that they are taking, and at minimum, they will not be receiving the medications that they were ordered.
This is exactly what happened in this incident. The nurse doing med pass dispensed medications for two residents, placed the medications into the medication cart and began the process of verifying the identity of the resident who would be receiving the medication. Before actually giving the medication, as the nurse described it, chaos broke loose with six (6!) nursing home falls occurring in a short period of time. She left to assess the residents who fell and get vital signs, and when she returned to give the resident she was caring for her medication, she took the medication for another resident off the cart and gave it to the resident.
This nursing home medication error was discovered a few minutes later when she went to administer medication to the resident whose medication had been dispensed in error. The nurse got vital signs and notified the doctor of the medication error. The medication that was provided in error had the potential to cause respiratory depression, so the staff was ordered to send the resident to the emergency room if the resident’s blood pressure or her oxygen saturation level dropped below a certain level. That was exactly what happened, resulting in the resident being taken to the hospital and being admitted to the critical care unit and placed on a ventilator due to respiratory failure.
There were obviously simple steps which if taken would have prevented this medication error. However, the chaos surrounding the multiple falls occurring during the medication pass prevented those measures from being properly taken. This is a prime example of how simple steps not taken in a nursing home setting can have disastrous consequences.
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.
Other blog posts of interest: