IDPH has cited and fined Palm Terrace nursing home in Mattoon after staff there failed to give a prescribed antipsychotic medication to one of the residents, leading to a breakdown of the resident which required the resident to be hospitalized and undergo electroconvulsive therapy.
The resident at issue had a history of mental illness and was discharged from the hospital to the nursing with an order to receive an injection of an antipsychotic medication called Invega approximately two weeks after admission to the nursing home. The nursing home apparently failed to order the medication, and by the time that the due date for giving the medication came, the pharmacy which supplied the medication informed the nursing home that the medication was not covered by the resident’s insurance. As a result, the resident did not receive the medication.
About two weeks after the missed dose of the medication, the resident experienced a psychiatric breakdown which involved him being threatening to the staff and refusing to keep his clothes on. The resident was brought to the hospital and admitted to the psychiatric unit where he underwent three rounds of electroconvulsive therapy in an effort to resolve the breakdown.
There were at least two major breakdowns in the care that this resident received.
First was the medication error which resulted in the resident not receiving the Invega which was prescribed for him. When a resident is going to be admitted to a nursing home, the admissions staff receives and reviews information about the resident to ensure that they can meet the care needs of the resident. If they can’t, the proper course is to deny the admission. One of the pieces of information that they receive is a list of the medications which have been prescribed so that they can order the medications to have them ready or on order when the resident is admitted. There was clearly a breakdown in this process – otherwise, the medication that the resident needed would have been on order when the resident arrived. If it could not be obtained, then other measures had to be taken.
Second was the failure of the nursing staff to notify the doctor that the medication which he prescribed was not being given to the resident. Doctors generally work on the assumption that their orders will be followed and that prescribed medications will be given. If this medication could not be obtained and was not given to the resident as ordered, the doctor was required to be notified so that he could determine what other course of action to take. Simply not giving the resident critical medications and hoping for the best was never an acceptable course of action.
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Other blog posts of interest:
Marshall Rehab resident fractures back in van accident
Taylorville Skilled fails to obtain anticonvulsant medication for resident
Flora Gardens staff fails to give antibiotic, leading to death of resident
Medication error at Palm Terrace leads to hospitalization
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