State Findings:
On [DATE] at 12:22 p.m., an Immediate Jeopardy (IJ) situation was verified with the Oklahoma State Department of Health regarding the facility’s failure to accurately transcribe the physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. The resident was subsequently transferred to the hospital and later died due to complications of [MEDICATION(S)] toxcity.
At 1:19 p.m., the facility administrator and the DON were informed of the IJ situation related to the facility’s failure to to accurately transcribe the physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] #9. A plan of removal for the IJ situation was requested.
RN #1 was asked to review the facility’s Residents Physicians Order Summary, dated [DATE]. She reviewed the orders and was asked what it documented as the order for [MEDICATION(S)]. She stated a two ten milligram tablets by mouth for seven days. She was asked if this was the correct order. She stated, No. RN #1 was asked if someone had verified the order with her. She stated LPN #1.
RN #1 was asked if there had been a Black Box warning for the metotrexate. She stated there had been. She was asked what the warning had said. She stated that it could be fatal.
RN #1 was asked what she had done about the Black Box warning. She stated she had faxed it to (physician’s name deleted). She was asked if he had responded back. She stated, No or I don’t know. She was asked if she had followed up with the physician. She stated, No. She was asked if someone should have followed up. She stated yes they should have.
RN #1 was asked if there had been a system warning about about the dosage of the [MEDICATION(S)]. She stated, Yes. She was asked what it said. She stated it said it was outside the recommended dose. She was asked if this information was faxed to the physician. She stated it should have been, that it usually was.
RN #1 was asked if she had received any follow-up regarding the [MEDICATION(S)]. She stated, No. She was asked if someone had followed up with the physician. She stated, No.
RN #1 was asked if medications had been given appropriately according to orders from the physician. She stated, Not in this case, no.
The State Medical Examiner’s Report of Autopsy, for resident #9, dated [DATE] at 1:00 p.m., documented, . CAUSE OF DEATH: COMPLICATIONS OF [MEDICATION(S)] TOXICITY .
The State of Oklahoma Certificate of Death, for resident #9, received [DATE] and certified [DATE], documented, .CAUSE OF DEATH .IMMEDIATE CAUSE .COMPLICATIONS OF [MEDICATION(S)] TOXICITY .
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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.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
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