CEO responds to nursing home death caused by wrong meds
Investigators from the Minnesota Department of Health concluded Fair Oaks Lodge neglected three residents by giving them the wrong medication or administering medication at the wrong time, leading to the death of one of them. A spokesman for the nursing home said a human error was made, medication disbursement procedures have been changed and the home's changes recently resulted in high marks on an inspection.
In a report released Friday, March 5, MDH ruled "the preponderance of the evidence indicates that neglect did occur when medications were given in error" to a Fair Oaks resident, an incident that led to her death. The report also said other "significant medical errors" were made during that time.
"We self-reported this to the state according to the provisions of the laws, as well as knowing this was the right thing to do," said Joel Beiswenger, CEO of Fair Oaks. "We did a full disclosure discussion with the family as soon as this happened and admitted the error. We're not denying there was an error."
Beiswenger said the staff of Fair Oaks has been retrained to ensure a similar medication mix-up doesn't happen in the future.
"It's a tragic human error," he said. "We've very sorry for the family of this resident that they experienced such a significant loss. We wish we could have changed the past here, but the best we can do is do everything in our power to make sure that something like this never happens again."
The names of the residents were not included in the report, referring to them only as "Resident #1," "Resident #2" and "Resident #3." Staff members were not identified, either. Beiswenger declined to identify the woman, citing HIPAA privacy laws.
But the Pioneer Journal learned the woman was Eunice Schwartz, a homemaker who "raised five good kids -- all adults living across the U.S. -- Colorado, Utah, California and two in Minnesota," said the Schwartz family's attorney, Jeff Stowman of Detroit Lakes.
Schwartz died just 37 days after being admitted to Fair Oaks in April 2009 due to advancing Alzheimer's disease. Around 7 p.m. on June 1, 2009, Schwartz was given medication meant for another patient, including lithium carbonate, a central nervous system medication; Inderal, a medication to treat heart arrhythmias; Clozaril, an anti-psychotic used to treat schizophrenia; and Lorcet, a pain medicine made up of Tylenol and hydrocodone. The Fair Oaks employee recognized the error about 10 minutes later and contacted the hospital emergency department physician, who advised the facility staff to monitor the resident's neurological status and take her blood pressure in a half-hour. In that time, the woman's blood pressure dropped to 58/42, she was breathing with pursed lips, periods of 15-second apnea were noted and her pupils were fixed and non-responsive, according to the report. She was taken to the emergency room and admitted into the intensive care unit. She was taken off life support on June 4 and died on June 7, 2009.
On June 8, 2009, another woman was admitted to Fair Oaks for physical rehabilitation following a fall in her home. On June 12, she was also given medication meant for another patient, and was rushed to the emergency room at the hospital. That resident remained there until early the next morning, when she recovered and was discharged back to the home on June 13.
A third incident detailed in the report says a resident on May 27, 2009 was given his scheduled doses of medication too close together -- at 3:45 p.m. and 5:50 p.m. -- and became unresponsive for two to three minutes, with weak pulse and non-reactive pupils. That resident was taken to the hospital's emergency room for monitoring, and recovered with no further complications.
What came next
Beiswenger said the employee involved in the death was disciplined according to Fair Oaks' policies, retrained and eventually put back to work. He said the staff member was "a good employee who made a human error." However, that staff member eventually left Fair Oaks to seek employment elsewhere.
The family took the death hard, Stowman said. He said Eunice Schwartz's Alzheimer's wasn't very far along, but her husband of 55 years, Roy, fell and hurt his knee. He couldn't care for Eunice like he wanted to, so he planned to bring her to Fair Oaks until his knee improved to the point he could care for her again.
Stowman said Roy told him, "If I'd only been able to keep her at the house, she'd still be alive."
Eunice and Roy spent their whole adult lives together in Wadena, Stowman said. In addition to being a homemaker, she worked briefly at Pamida.
Beiswenger and Stowman both said the family and the nursing home's insurance agency and attorney are in settlement talks, "but those talks have broken down," Stowman said.
Reports of errors made
Beiswenger said the MDH report and media reports have mentioned an 18 percent medication error rate, which is misleading.
"That does not imply we have an annual error rate of 18 percent," he said.
After the incident, health department inspectors viewed two rounds of medication distribution in one day at the nursing home, and found an 18 percent error rate during those rounds. However, Beiswenger said, it's very difficult to get a perfect score, as delaying someone's medication even five minutes can result in an error.
But he said the most recent annual inspection in February found an error rate of zero.
"We're very confident right now that everything is in order," Beiswenger said. "Our residents are in great hands and very safe, and the residents' families should be at ease."
Beiswenger said he hasn't been notified of any disciplinary action by the health department. He also said the nursing home has been working with the deceased woman's family toward a settlement since the incident happened, but none has been reached yet.
Fair Oaks can appeal the findings of the MDH inspectors, but Beiswenger said he doesn't know if they'll end up doing that.
"Haven't decided yet," he said. "It's still pretty fresh for us in terms of [receiving] the final report."
He said it's the first time something like this has happened at Fair Oaks.
Stowman said he "sincerely hopes this never happens again to anybody."