CHICAGO FACILITY FINED FOR MEDICATION ERRORS

SPRINGFIELD, Ill. – The Illinois Department of Public Health has fined Warren Barr Pavilion $10,000 (Statement of Violation) for failure to ensure that residents receive medications as prescribed, to train temporary nursing staff on the administration of medications and to address complaints regarding ongoing medication errors. The 271-bed skilled care facility is located at 66 W. Oak St. in Chicago.

As part of an annual inspection and complaint investigation, Department surveyors learned a resident was hospitalized after mistakenly given his roommate's medications.

According to interviews, an agency nurse gave the resident his medication as well as his roommate's pills to control blood pressure and heart rate and an antidepressant.

The resident said the agency nurse also had tried to administer insulin, but he told her that he did not take insulin. The resident experienced acute medical changes and was admitted to the hospital for low blood pressure and a low heart rate.

Another employee said the agency nurse did not ask the resident his name or check his identification band prior to giving the medication. Surveyors found there was no consistent method used by nursing staff to check patient identities prior to giving medications and temporary nurses, who were not familiar with residents, were often used to distribute medications.

A grievance log listed five complaints in a one-month period involving medications not given, medications not given in a timely manner or medication errors. Although these incidents were investigated by the facility, there was no evidence a comprehensive plan was established to prevent medication errors in the future.

Warren Barr Pavilion did not request a hearing and paid the fine.