IDPH has cited and fined Sharon Healthcare Elms after a resident received two times the initially prescribed medication needed to treat his Diabetes Melitus leading to a drop in blood sugar that required hospitalization.
When a resident is admitted to a nursing home from a hospital, one of the things that the nursing home receives at the time of the admission is a list of prescribed medications and orders to be followed by the nursing home. When the transfer orders are received, these are customarily entered into the resident’s chart by the admitting nurse. In well-run nursing homes, the entry of these orders is double-checked to ensure that all of the orders are entered into the chart correctly. Assuring continuity of care is absolutely crucial to assuring the health and well-being of nursing home residents because the failure to give ordered medications or to carry out treatments or orders can have catastrophic consequences.
The resident at issue here was admitted to the facility with a diagnosis of Type 2 Diabetes Mellitus. Diabetes is a common ailment treated in nursing homes. To keep blood sugar levels properly controlled, medications are commonly given. One is Glipizide which when taken brings blood sugar levels down. Too much Glipizide can result in excessively low blood sugar levels or hypoglycemia. The discharge medication instructions from the hospital indicated Glipizide (XL)2.5 mg 24 hour sustained release tablets, once daily. In this case the nursing home made a transcription mistake, resulting in the resident receiving Glipizide (XL) 2.5mg twice daily.
Fortunately, there was a consultant pharmacy that notified the nursing home via fax on two separate occasions that there was a discrepancy in the quantity of the medication. In well run nursing homes, the moment a nurse receives the fax, he or she addresses the mistake immediately. Neither of the faxes that were sent directly to the nursing station were acted upon and the resident continued to receive Glipizide twice daily.
The additional medicine resulted in the resident becoming unresponsive, hypoglycemic and requiring transfer to the hospital via ambulance.
Obviously, this nursing home medication error led to this resident experiencing a life threatening medical event. The initial transcription error is clear, but the nursing home also failed this resident by not acting upon the faxes the pharmacist sent over to the nursing station.
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