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SANTA ROSA, CA — March 11, 2005 — A seventy–six year old woman died within a day of receiving a diabetic’s medication that dangerously lowered her blood sugar. She was a nursing home resident who had terminal colon cancer, not a diabetic.
Staff members at Memorial Hospital’s Sotoyome Street nursing home were preparing to release the resident to her family to spend her final days in peace. Instead, a nurse admitted that he “forgot to check her armband” and gave her medicine intended for another patient. The incident took place last May. However, it only became public recently after a local newspaper, the Press Democrat, reported the results of an investigation by the state Department of Health Services (CDHS).
The CDHS blamed both the nurse and the nursing home for the fatal error. “The facility failed to properly assess the dangers of a medication error and failed to notify the resident’s physician promptly of the error, which was life–threatening,” the CDHS report said (Press Democrat, March 3, 2005).
The CDHS gave the Sotoyome facility an “AA citation,” which is the most serious category of violations in California. It was also fined $50,000. Fourteen similar fines were levied in California last year, according to the newspaper. Memorial Hospital was also cited in 2000 when a nursing home patient died from an infection.
Medication errors occur at the rate of 1 in 5 doses in a typical hospital or skilled nursing home, according to a 2002 study of Colorado and Georgia health care facilities (Arch Intern Med 2002 Sep 9; 162(16): 1897–903). Another report found 815 prescription drug errors in two nursing homes over a two–year period (Am J Med. 2005 Mar; 118(3): 251–8). These occurred mostly at the ordering or monitoring stage.
One suggestion for avoiding medication errors is to use electronic aids such as bar codes. This uses a scanner to match a code on the patient’s wristband with a code on the medicine container. A deeper problem, however, is the stress and work overload that nurses and other staff may experience on their rounds. As a nurse has more patients to contend with, the possibility for human error and mix–ups increases.
Each California nursing home resident is supposed to receive a minimum of 3.2 patient hours of care per day, and a nursing home is required to hire enough staff to fulfill this obligation. “Nursing hours” include the working hours of aides, nursing assistants, and orderlies as well as licensed nurses. Many facilities do not live up to these minimum standards, which are meant to ensure the well–being of nursing home residents.
At Brayton Purcell, we are concerned with the well–being of seniors in nursing homes and in our community. We can help you with problems such as nursing home violations and inadequate pain management. If you have questions about a nursing home and your legal rights, or the rights of an elderly loved one, please feel free to contact us for more information.
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