Circle Drive Manor Assisted Living West Concord Allegations of Neglect After Wrong Medications
In a report from the Minnesota Department of Health, dated January 19, 2017, there was an allegation that a client at Circle Drive Manor Assisted Living West Concord was neglected when the facility administered an incorrect medication to the client and the client developed severe respiratory distress.
Circle Drive Manor Assisted Living West Concord Neglect Substantiated
Based on a preponderance of the evidence, neglect occurred when a client was given the wrong medication by the facility staff. The client required hospitalization and intubation due to receiving the incorrect medication. The facility had a pattern of presetting medications in a manner which made this issue likely to occur, the facility has been informed this practice was not safe, and the facility continued to fail to provide safe medication administration after this incident.
The client had a diagnosis that included chronic obstructive pulmonary disease (COPD). The client required oxygen use to maintain the client’s respiratory status. The client received home care services and required assistance with all activities of daily living including medication and oxygen management. The client had a history of respiratory infections and exacerbation of COPD.
The day of the incident, the client was not feeling well and requested to eat in his/her room instead of eating in the dining room. The alleged perpetrator (AP) stated at about 11:00 a.m.. s/he prepared another client’s medication (gabapentin 600 milligrams), which was due at noon. The AP stated that after setting up the medication, s/he delivered the client his/her lunch tray, but accidently placed the other client’s medication on the tray. The AP continued to serve lunch to other clients in the dining room. At 11:30 a.m., the AP went to the medication cart to administer the gabapentin and found that the medication cup with the pills was no longer there. The AP verified s/he had signed his/her initials on the medication card, indicating s/he had set up the medication. The AP stated s/he went back to the client’s room and noticed an empty medication cup on the client’s lunch tray. The client was unresponsive. Immediately, the AP called emergency medical services, and the client was sent to the hospital.
At the hospital, the client was intubated due to compromised respiratory status. The client was extubated the following day and hospitalized for three days. The hospital physician indicated the client would return to previous status with ongoing chronic health issues. Upon discharge, the client returned to the home care provider. The client subsequently declined in health status related to heart and lung diseases. The client died approximately one month later. The client’s death record indicated the client died from natural causes.
The client’s physician was interviewed and stated it was coincidental that the incident of the medication error occurred a month prior to the client’s death. The physician stated the client had a severe heart blockage which was apparently the ultimate cause of death.
During an interview, the AP stated s/he made the medication error on a busy day. The AP stated that because the client was underweight and frail, once s/he realized the error had occurred, s/he called the emergency services immediately to treat the client.
During an interview, a nurse who previously worked at the home care provider stated that both before and after this incident, unlicensed staff members would set up medications ahead of time, although they had been trained not to do so. The nurse stated s/he had spoken to the owners of the facility, including the AP, regarding this pattern of unsafe medication administration, and the AP did not change the practice. The nurse’s company terminated their contract with the facility due to this practice.
During the investigation, both the AP and another unlicensed staff member were observed setting up medications for multiple clients at the same time. This included an incident where medications, scheduled to be administered at 5:00 p.m. and 8:00 p.m., were placed in medication cups between 3:50 p.m. and 4:20 p.m. These medications were then locked in a tool chest for later administration to the clients.
Report Medication Errors and Other Elder Abuse and Neglect
For more information from the Minnesota Department of Health, Office of Health Facility Complaints concerning nursing homes, assisted living and other elder care providers view resolved complaints at the MDH website.
If you have concerns about being given the wrong medication or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.