IDPH has cited and fined Arista Healthcare nursing home in Naperville after a resident did not receive medications needed to treat his rheumatoid arthritis leading to a flare-up of the disease which required hospitalization.
When a resident is admitted to a nursing home from a hospital, one of the things that the nursing home receives at the time of the admission is a list of prescribed medications and orders to be followed by the nursing home. When the transfer orders are received, these are customarily entered into the resident’s chart by the admitting nurse. In well-run nursing homes, the entry of these orders is double-checked to insure that all of the orders are entered into the chart correctly. Assuring continuity of care is absolutely crucial to assuring the health and well-being of nursing home resident because the failure to give ordered medications or to carry out treatments or orders can have catastrophic consequences.
The resident at issue here was readmitted to the nursing home from the hospital after experiencing a rheumatoid arthritis flare-up. When Assuring continuity of care is absolutely crucial to assuring the health and well-being of nursing home resident because the failure to give ordered medications or to carry out treatments or orders can have catastrophic consequences. When the resident was brought into the facility by paramedics, they brought paper copies of the discharge orders from the hospital. These were taken by the receptionist and scanned. However, due to a scanning error, only 4 of the 5 pages were scanned, and as a result, there was a whole page of medications that were prescribed for the resident that was never entered into the resident chart. This the sort of error which double checking the chart against the transfer orders is supposed to catch, but no one actually did the double checking, so the error was never caught, and as a result, the resident did not receive the medications on the missing page.
Unfortunately, two of the medications which were listed on the missing page were medications which were critical to keeping the resident’s rheumatoid arthritis under control. Over a thirteen day period, the resident did not receive these medications, and the resident experienced a repeat flare-up of the rheumatoid arthritis. The error was finally discovered when the resident was admitted to the hospital from his rheumatologist’s office because he was experiencing severe pain and had obvious signs of a flare-up.
Obviously, this nursing home medication error led to this resident experiencing significant unnecessary pain. The source of this error is clear, but the nursing home also failed this resident by failing to notify the resident’s doctor about the severe pain that the resident was experiencing.
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