Bartow Center Neglects to Check Dosage of Medications, Sends Resident to Hospital
Bartow Center has been cited for failing to reconcile multiple lists of medications and administer proper dosages to a new resident. Because of this, a resident could not be woken from his sleep and was immediately sent to the hospital for low blood glucose levels.
The resident in this citation was admitted as a hospice resident for a five-day stay. The nurse who admitted the resident to the facility spoke with him shortly after his arrival and asked the resident to sign a consent-to-treat form. She had to repeat herself loudly when talking with the resident, but he was otherwise aware of his surroundings and seemed to understand the nurse’s intent.
The family arrived shortly after the resident was admitted. They brought clothing for the resident and a small box of pill bottles and piece of yellow notebook paper with handwritten medication orders. The nurse took the yellow notebook paper with the medications and compared it to the typewritten list she’d received from hospice when the resident arrived. In an interview, the nurse said that the facility’s Unit Manager told her to compare the two lists of medications; if they were different, she was to use the handwritten copy provided by the family. The nurse did not identify any differences between the two lists. She also did not consult hospice or a physician to verify the medications were correct. Rather, she used the handwritten note and the family’s instructions.
At this facility, there is a policy in place regarding medications brought in for new residents. This policy is in place to protect the resident from incorrect dosages and ultimately life-threatening mistakes. Medications brought into the nursing care center by a resident or responsible party (like the family) are accepted only with a current order by the resident’s prescriber. The medications also have to be verified by the nurse, and the packaging must meet the state, federal, and pharmacy guidelines.
In the afternoon, the nurse administered 20 units of insulin per the instructions of the resident’s daughter. Since the nurse didn’t know this resident’s medical condition well, she checked his blood glucose level. She also confirmed there wasn’t a sliding scale for the insulin. A sliding scale helps determine how much insulin should be administered before a meal. The daughter told the nurse her father got 20 units three times a day. So, the nurse administered the first dose at 2 p.m.
As the nurse got ready to leave for the day, she greeted the incoming nurse and explained the new admission. The resident had eaten less than half of the lunch meal and was sleeping when she left. Around dinner time, a new nurse came to provide a meal. She reported she was not able to wake the resident, even after shaking him. After leaving the room to enlist the help of another nurse, the family arrived at the resident’s room. The nurse returned to find the family “very upset.” They were yelling for a nurse and making a call to 911.
In an interview with a hospice patient care administrator, she confirmed the resident did have a sliding scale. This was not what the daughter had told the first nurse who administered the insulin at lunch time. After the hospice patient care reviewed the list of medications provided to the nursing home, she confirmed the amount of insulin was not always 20 units; there should have been a sliding scale included in the list. She reported that she was “sure” the family would’ve been aware of the sliding scale and could’ve reported it to the nurses. A family member confirmed that the medication for her father was based on a sliding scale, which she verbally told the nurse when she handed over the resident’s medicine. She said that the resident’s blood sugar was to be checked before his meal and insulin given based on the result and the sliding scale.
Nursing home residents rely on nursing homes to follow their own procedures so their lives are not put at risk. Although mix-ups can happen, nursing homes must be thorough and careful when administering medication. One mistake could cost a resident his or her life, so it’s imperative a nursing home staff are diligent about checking medications. Although family members mean well when providing instructions for medications, they can still make mistakes. This is why a physician should always be consulted before medications brought into a facility are administered.
The nursing home in this citation did not properly care for a new resident because they did not follow their procedures for medications. Because the nurse took the family’s instructions above a physician’s, the resident needed to be hospitalized only a couple of days after his arrival. When families admit their loved ones into the care of a nursing home, they need to be sure their loved one will be taken care of when they cannot be around. Had the facility followed its procedure for confirming medications, the resident could have remained safely in the facility for the remainder of his stay.
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