State Findings:
The facility failed to ensure Resident #1 was not administered four times the ordered dose of [MEDICATION NAME] on two occasions and contributed to his functional decline, which ultimately led to the resident ‘ s death.
On 11/13/2020 the resident was administered [MEDICATION NAME] 1 ML at 4:30 p.m.
One 11/14/2020 the resident was administered [MEDICATION NAME] 1 ML (more than the ordered dose) at 1:00 a.m. At 1:30 a.m. the resident was administered [MEDICATION NAME] Solution 0.5 ML at 1:30 a.m.
One day later, Resident #1, again, was administered 1 ML of [MEDICATION NAME], two to four times the ordered dose by the physician, and was a significant medication error.
Licensed practical nurse (LPN) #3 was interviewed on 3/10/21 at 1:58 p.m. She said she had cared for Resident #1 while he was at the facility. She said she did not believe the resident was supposed to receive more than 0.25 ML of [MEDICATION NAME] at one time. She said 1 ML of [MEDICATION NAME] could cause sedation and could have contributed to Resident #1 functional decline. She said administering 1 ML of [MEDICATION NAME] would be considered a significant medication error due to the seriousness and type of the medication.
The director of nursing (DON) was interviewed on 3/10/21 at 5:42 p.m. She confirmed Resident #1 was administered 1 ML of [MEDICATION NAME] on 11/13/2020 and 11/14/2020. She said the resident was administered four times the physician ordered dose of [MEDICATION NAME]. She said Resident #1 had experienced a sudden functional decline. She said she was unaware, until it was brought to her attention during the survey process, Resident #1 was administered an excessive dose of [MEDICATION NAME] on two occasions. She said if a medication error was observed, then a medication error investigation would be conducted. She said she did not have documentation a medication error investigation occurred regarding Resident #1.
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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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