New Perspectives Columbia Heights Failed to Administer Medication
It is alleged in a report dated November 8, 2016 from the Minnesota Department of Health, that the Lighthouse of Columbia Heights aka New Perspectives neglected a client when staff failed to administer prescribed medications for pneumonia. The client had a change in condition when s/he was assessed and found to be deteriorating. The client was later hospitalized and passed away.
Substantiated Neglect Against New Perspectives – Lighthouse of Columbia Heights
Based on a preponderance of the evidence, neglect is substantiated. The home care provider staff failed to administer a client an ordered antibiotic for pneumonia. The client developed pneumonia and sepsis, was hospitalized, and died.
The client received services from the home care provider for diagnoses that included diabetes and failure to thrive. The client required assistance with medication administration. The provider order for life sustaining treatment (POLST) indicated the client choose not be resuscitated, but marked “yes” to the use of antibiotics. The client experienced a slow decline in health status including decreased appetite with weight loss, increased incidence of falls, and not sleeping well. One Wednesday, the client was seen by a nurse practitioner to address insomnia and weight loss. The next day, the client experienced a cough, runny nose, and fatigue. That Friday, the staff updated the nurse practitioner, who ordered a chest x-ray which found mild pneumonia. On Saturday at 11:00 a.m., the physician assistant prescribed an antibiotic and sent the prescription to the pharmacy.
The pharmacy delivered the antibiotic on Saturday evening at 5:20 p.m. A staff member who was not assigned to the client received the pharmacy delivery and brought the antibiotic to the staff member who was assigned to administer the client his/her medications. The staff member stated he/she placed the medication in the bottom drawer of the medication cart and continued with passing medications to clients. The client’s antibiotics was scheduled to be given at 8:00 p.m. Each medication had two different names, a trade name and a generic name. Although both the trade name and the generic name were listed on the electronic medical record (EMAR) and the antibiotic supply card, the staff member omitted the medication and commented on the EMAR that the antibiotic was not available. The next day, a different evening staff member also commented that the antibiotic was not available, and omitted the medication.
On Monday, the licensed practical nurse (LPN) went to check on the client’s status. At that time, the LPN found that the client had not received any of the prescribed antibiotic (two doses) for pneumonia. The LPN changed the antibiotic administration time to 2:00 p.m., found the antibiotic supply card in the bottom drawer of the medication cart with no tabs used, administered the first dose, and updated the registered nurse (RN). The RN investigated which staff had omitted the antibiotic and educated those staff members. The LPN stated the client experienced increased weakness, coarse cough, elevated respiration rate of 28, and an elevated heart rate of 106. The home care staff updated the physician on the medication error and the client continued to decline in condition. Late that evening, the client was sent to the hospital for evaluation. The hospital attempted intravenous antibiotics, but the client passed away on Friday. The client’s death record indicated the cause of death was pneumonia and sepsis.
An interview with the client’s physician stated that although the client’s x-ray showed mild pneumonia, the client present clinically ill enough to require an antibiotic. The physician explained that because the client’s comorbidities that included congestive heart failure, diabetes, and chronic anemia, the delay in starting an antibiotic could have led to client to progress into sepsis.
During interviews with staff, on staff member stated s/he did not realize the antibiotic on the EMAR was the same as the antibiotic delivered that day for the client by the pharmacy. Therefore, the staff member stated s/he thought it had not been delivered yet. The other staff member stated s/he could not find the antibiotic in the medication cart and because it was marked not available the day before, assumed it still had not been delivered. Both staff members stated they normally update the nurse when a medication is missing, however they did not report a missing medication to the nurse with this incident.
For more information about medication errors or elder abuse and neglect related injuries call Kenneth LaBore for a free consultation at his direct number at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.