Stephanie Flemmons at sflemmons@acnpapers.com had a great article in the Plano Courier. The article discusses how a complaint was handled by the state agency responsible for investigating nursing home resident's complaints. Richard Ward was a resident who received a serious medication error that could have killed him. The Texas Department of Aging and Disability Services ruled not to take any action against a facility that almost killed him.
“It strikes me as, you may have made a medication error that could have killed someone, but oh well,” Ward said. “We are not working on cars here, we are working on people.”
Ward’s formal complaint stated that the Life Care Center of Plano failed to administer the proper medication, which almost caused a fatal heart attack. When Ward admitted himself to Life Care, he provided the nursing staff with an itemized list of the types of medications he was required to take, what the dosages were and the actual medications.
Ward said the nursing staff failed to administer his Coumadin. He became aware days later when his physician conducted her examination. “When the doctor conducted her physical it was almost too late,” Ward said. “She panicked after the results from an INR test came back normal. A normal level for a person with my heart conditions is a dangerous place.”
The physician immediately ordered Lovenox injections and Coumadin. “I felt like I was on the brink of death,” Ward said. “I panicked.”
That night on May 28, Ward received his required Coumadin. The next day the errors kept occurring. He received his Lovenox the next morning, but did not receive it that night.
“Medication time is at 9 p.m. and I waited until 10:30 p.m. to ask the nurses,” Ward said. “They argued with me. I had to force them to look it up.” Ward said they realized they made a mistake, but at that point he had had enough. “I thought these people were going to kill me,” Ward said. “That was their last chance.”
The state agency ruled this claim as unsubstantiated or unverified.
“I am flabbergasted,” Ward said. “I brought them a typed list of every medication that I picked up from the Medical Center of Plano before I admitted myself.” Ward discharged himself from Life Care. He reviewed his medical records. The typed list was no longer in the records.
“They took it out because it showed blatant negligence,” Ward said. “All they had to do was lose one piece of paper and they wouldn’t look so bad.”
Ward’s second complaint alleged that the facility failed to maintain accurate clinical records. DADS did find that the facility did have his name incorrect, but they did not issue a citation.
“How would they know who they were giving medicine to if they did not have the patient’s correct name?” Ward said. “At some point they gave me medicine, without the correct name on my records.”
Ward wrote prescriptions for 20 years in the Army and as a civilian. He is concerned that the state agency’s rulings on both claims proves future such rulings could take the life of an innocent person. “You just can’t make a mistake like this and not have any repercussions,” Ward said. “If they are doing this to someone who is awake and alert and knows how to read medical records, I’m sure they are doing this to someone else. I’m not an isolated case.”
Ward said they never contacted any of his family members or even asked him many questions regarding the claim. According to DADS annual report, medication errors are No. 8 in their top 10 list for complaints.
