IDPH has cited Alden Town Manor nursing home in Cicero after a resident there was given glipizide when it was not part of his medication regimen.
Almost all nursing home residents receive medications on a regular basis. To ensure that residents receive medications as ordered, nurses are supposed to follow the five “rights” in administering medications: right patient, right medication, right dose, right time, and right route. Not getting all five “rights” just right can result in a critical nursing home medication error. Sadly, that is what happened here.
The resident was admitted for treatment of a urinary tract infection. While he was a diabetic, glipizide was not a part of his medication regimen. Glipizide is a type of medication known as a sulfonylureas. These medications stimulate the release of insulin from your pancreas, directing your body to store blood sugar. This helps lower your blood sugar levels. However, when taken by someone who does not need this medication, it can drive their blood sugar down to critically low levels. Abnormally low blood sugar levels is known as hypoglycemia. Hypoglycemia can have widespread negative effects on your health and well-being.
When the resident was initially admitted to the nursing home, he was anxious and restless. However, 5 days later when the nurse went to do the afternoon medication pass, she was unable to rouse him. She checked his blood pressure and found that it was normal. She then checked his blood sugar and got a result of 24 (normal range 140-199), which is a critically low result.
When the resident was sent to the hospital where a screening test showed that he had glipizide in his system. The diagnosis was neuroglycopenic injury secondary to hypoglycemia. He had to be intubated in order to protect his airway. When he was extubated, he was still unresponsive. A PEG tube had to be place for long-term nutritional needs due to the brain injury he sustained. He was discharged from the nursing home, where the staff described him as being unresponsive to stimuli.
Investigation at the nursing home showed that there was only one other resident who had an order for glipizide and he was in the room across the hall from the resident. These facts strongly suggest that the resident received the medication which had been ordered for the person across the hall. The system for avoiding just this kind of error was apparently not followed – the check for the right patient was not done – because there is no other way that the resident could have ended up with glipizide in his system.
The simple failure to follow this time-tested system resulted in a very avoidable medication error with catastrophic results. This resident suffered a catastrophic brain injury and is no longer capable of meaningful communication or voluntary movement. Chances are strong that complications from this medication error will result in the wrongful death of this resident, whether from bed sores caused by immobility, pneumonia, feeding tube complications, or any number of other complications that beset a severely medically compromised patient like this resident.
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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