Nursing Home Medication Errors Leading to Hospitalizations

Medication errors in Illinois nursing homes are leading to hospitalizations for dangerously low blood sugar, visual hallucinations and labored breathing, according to information obtained by NBC 5 Investigates via a search of public records.

State health inspectors documented 384 nursing home medication errors since 2011. Two residents of care facilities died after recorded medication errors and one resident's untreated infection led to an amputation, according to Illinois Department of Public Health data.

"You're going to have errors, unfortunately. But we hope that there are no errors due to negligence," said IDPH director LaMar Hasbrouck, MD.

Tanya Karney-Brown moved her brother, Joseph, into The Renaissance Park South nursing home in Roseland back in 2005 after Joseph had suffered a stroke and a heart attack.

"We checked it out. Everything was fine. So we felt that would be the perfect place," Karney-Brown said.

Two years later Joseph was diagnosed with gastrointestinal cancer. Karney-Brown said Joseph responded well to his cancer medication, Gleevac.

Months later, however, Joseph's condition changed.

His family discovered the nursing home did not give Joseph his cancer medication for nearly one year. According to a lawsuit filed by the family, the nursing home failed to get Joseph back to his oncologist for follow up appointments.

By the time the error was noticed, Joseph's cancer had spread. Joseph passed away in early 2010.

"He could have been still here, you know, doing what he does best and getting better," Karney-Brown said. "But now unfortunately, he's not here anymore."

Joseph's family filed a lawsuit and reached a settlement with the nursing home.

"We regret that the incident occurred and used it as an opportunity to better ourselves and the care we provide," wrote The Renaissance Park South administrator Rolando Carter in a statement to NBC 5 Investigates.

According to Carter, the facility has since partnered with a national pharmaceutical provider to ensure proper distribution of medication to each resident they serve. He wrote the facility also performs regular audits to ensure medications are being dispensed properly and timely.

"Our top priority is the health and safety of our residents and we take every precaution to ensure that highest level of care," Carter wrote.

Hasbrouck said Illinois currently has a 9% facility citation rate for medication errors. He said that compares "favorably" to the national average. However, Hasbrouck said the state's goal is a 5% citation rate.

"We can do better and that's one of the reasons why we've stiffened some of the requirements," Hasbrouck said.

Health inspectors monitor care facilities' training standards and operating procedures and systems for protection in terms of medications. Facilities face fines and penalties for documented medication errors. They can also be shut down or not re-certified

Sometimes handwriting can cause errors in terms of dosage, Hasbrouck said. The errors can result in a resident getting the wrong medication, too much medication or not enough medication.

"They (nurses) have to be very, vigilant in terms of how they give it and make sure they give it on time, every time so that we can minimize any risk," Hasbrouck said.

Nursing homes in Illinois provide care to more than 85,000 people who on average take 10 prescription medicines per day, according to the Health Care Council of Illinois. "The stakes are high in any healthcare setting, and human error exists in every profession-in every aspect of society," said HCCI executive director Pat Comstock. "Nursing home professionals work hard every day in an effort to eliminate it."

The Illinois Health Care Association is an advocacy group that represents care facilities across the state. IHCA president John Vrba said the long term care sector has done a lot of work trying to prevent medication errors.

"We don't want any medication error. One medication error is one too many," Vrba said.

Vrba said underfunding in Medicaid does not help the cause, but he said collaborative work with the state is needed to combat medication errors. He said continued education for nurses and limited interruptions during medication passes will help limit mistakes.

Nursing homes are also hiring admissions nurses with advanced skill sets and using automated medication dispensers in their efforts to cut down on medication errors. Facility staff members are also using TALL MAN letters, Vrba said, to differentiate look-alike drug names. For example, noting predniSONE as opposed to prednisoLONE.

"This is just another way that I believe all facilities throughout the state or anybody passing a medication should utilize to prevent an error," Vrba said.

The state urges families to research a facility's complaint and citation history before placing a loved one in a care facility.

"Safety and quality of care is a collective responsibility," Hasbrouck said. "The family has a responsibility to do their due diligence."

Karney-Brown said once your loved one is in a nursing home, go visit them often and show up unannounced.

"If something feels off, I think you should ask the question and find out right away," Karney-Brown said. "Don't just take yes for an answer or no for an answer."

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