State Findings:
Based on interview and record review, the facility failed to ensure the right to be free from any significant medication error was provided for 1 of 3 residents reviewed for significant medication errors. (Resident #1)
The facility did not administer [MEDICATION NAME] ([MEDICATION NAME] (antipsychotic) 10mg (milligram) twice daily as prescribed by the physician from [DATE] through 01/7/20 for Resident #1. He received an extra 20mg of medication for 20 days. Resident #1 began to become difficult to arouse and was sent to the hospital on [DATE] and was diagnosed with [REDACTED].
A neurology consult note dated 1/8//20 indicated Resident #1 was admitted to the hospital after his wife found him slumped over and unresponsive. The note indicated the wife also noted tremulous (shaking or quivering slightly) movements of his hands that could represent [MEDICAL CONDITION] activity. On admission the UA (urinary analysis) showed Resident #1 was positive for Leukocyte esterase (test to detect white blood cells in the urine), WBC (white blood cells) in the urine was 54 (range 0-10), and moderate bacteria was noted, antibiotics were started. Resident #1’s WBC (white blood count) on admission was 11.1 (normal range 4.5-11.0).
During an interview on 1/14/20 at 10:50 a.m., the DON said, on this particular order she messed up. She said the medication aide administered the wrong medication, but she is the one that put the orders in the computer. The DON said Resident #1 received more medication then what he was supposed to receive. She said the medication was the [MEDICATION NAME] ([MEDICATION NAME]). She said Resident #1 was supposed to get 10 mg twice a day but was administered 20 mg twice a day. The DON said she discovered the error 01/13/20 when Resident #1’s wife called and said that he had been getting the wrong dosage since [DATE] when there was a change in the order. The DON said Resident #1 was almost unresponsive, not answering questions, slow to respond, and would not follow commands when he was sent out on 01/07/20.
During an interview on 1/14/20 at 11:19 a.m., LVN A said on 01/07/20 Resident #1 was leaning over on the table in the unit and she thought he was sleeping. She said she checked the order and she went to the DON and ask her about the medication. LVN A said she did not know.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
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Personal Note from NHA-Advocates
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