The Minnesota Department of Health alleges negligence at The Waterford Manor independent and assisted senior living facility, after a client was given the wrong medication and later died.
The client was admitted to the facility with a service plan that included staff assistance for medication administration in mornings, afternoons and evenings.
According to a report, a staff member administered medication to the client at approximately 8 a.m., Dec. 20, 2016.
A staff member found the client unresponsive in her room prior to the scheduled noon meal. A nurse on the scene determined that the client should be sent to the emergency room for medical attention.
Hospital records indicated that a medication cup labeled “204” was found in the client’s pocket, according to the report. The digits indicated which room, where the client was to receive the medication. The client’s room number did not correspond with the numbers on the cup.
Hospital staff members contacted The Waterford and obtained a list of medications for room 204. The list included a dose of clozapine, an anti-psychotic medication primarily used to treat schizophrenia.
While the client was not prescribed clozapine, hospital lab tests concluded that it was present in her system.
She was admitted to the hospital for altered mental status. The client was later transferred to intensive care for close respiratory observation. In intensive care, “hospital records indicated the client initially improved but then ‘deteriorated again the following day with onset of fever and presumed aspiration,’” according to the report.
The client was transferred to another facility, where she died Jan. 5, 2017. Her death came nine days after being transferred and 16 days after the initial incident. Her death certificate stated that the manner of death could not be determined, and the cause of death was due to complications of aspiration pneumonia and metabolic encephalopathy.
“Inadvertent use of non-prescribed clozapine cannot be excluded as a contributing cause of death,” the death certificate read.
The facility’s internal investigation concluded there was “no reason to believe” that the client had received the medication intended for room 204. The client in room 204 said he had received his 8 a.m. medication.
The client also had a habit of picking up cups and other items and tucking them into her shirt or sleeves, according to staff members.
When asked by Department of Health investigators, the employee responsible for distributing the medication said she gave the correct medications to both clients, and denied giving clozapine to the client in question. She had a tendency to pick up items and puts them in her sleeves, the staff member said. Or, the client could have found the cup on the floor, or took it out the garbage, she said.
Waterford’s director of health services, who opened the internal investigation, requested toxicology reports from the hospital, but said they were not provided.
The Department of Health report concluded that, while Waterford Manor had policies and procedures in place regarding the administration of medication, it did not monitor to ensure these polices were implemented by its staff members.
While performing a medication pass observation on Jan. 27, 2016, a health department inspector reported improper storage of medication that had been refused by clients. An employee who was distributing medication stored refused cups labeled with room numbers in the top drawer of the medication cart until she could bring them to the nurse for proper disposal.
The director of health services said the nurse should be contacted immediately if a client refuses their medication so it can be disposed of promptly.
Contact Kevin Miller at [email protected]