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Calgirl Asked August 2021

What should I do about this medication error at rehab?

My father returned to his home from a rehab facility when his benefits ran out. He needed more care at home than he would admit to. Very stubborn and in denial. Long story short, he went home with one medication that was someone else's. I gave this to him for 3 days at least. His home care RN came to start the service and made a med list including the wrong one. Then I saw the wrong patient name on the blister pack, called the nurse and got no answer for over a day. Dad had deteriorated and we knew his heart and kidneys were failing. He passed away the next day. I'm not going to court to fight. I just want to protect other patients at this facility. I have not contacted the facility about this, but I told the home care nurse. Dad loved all the staff at the rehab place, and I think they're terrific. Except for the administrator who never answered any of my messages about a different issue. I don't want to trash these people. Now what?

JoAnn29 Aug 2021
I want to respond to OPs reply to me.

Please people be very aware of meds given to LOs and yourself. Question, question, question. Its easy to look up a med on the internet and see the side effects, what its for, what you don't combine it with. A pharmacist knows more about interactions than a doctor. Doctors get kick backs if they prescribe a certain medication. For my Mom, hospital had right on their screen under allergies that Mom was allergic to penicillin. She was given a broad spectrum antibiotic for a UTI with penicillin in it. My RN daughter thought she was dying. She found the error. Not the Nurses on the floor that I kept saying "there is something wrong". My Uncle was sent to the Hospital for an allergic reaction to a new lung medication. He was sent to rehab. The Nurse went to put medication in his IV. My Aunt asked what it was, turned out to be the medication that put him into the hospital.
Momheal1 Aug 2021
Sadly - I think it happens often - it has happened to my mom many times in the hospital - I would have each nurse bring the computer and review meds for each shift - one was added in overnight by the infectious disease dr and it was one of her Allergies that had given her toxic encephalopathy and couldn’t have been anymore on top of my moms meds and it still got slipped in on overnight rounds.
We all have to be incredibly proactive in not being afraid to ask questions and be an advocate for ourselves and others.
Cover99 Aug 2021
I'm so sorry for your loss.

Report to Medicare and see what they do.

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Momheal1 Aug 2021
I am so sorry for your loss. This is so sad and I can see why you wouldn’t want anyone to get into trouble after seeing how they cared for your parent - it has to be addressed so that they can fix and better protect from this happening again.

I witnessed a nurse give my moms roommate my moms medication in rehab and I had to report it. The roommate was very alert and always asked what she was being given and nurse was telling the roommate her “Lantus” (the roommate kept saying “I haven’t taken Lantus in months and months” - the nurse told her well the dr has you back on it as it’s in your meds to start tonight - anyhow moms meds were next and that’s when I realized it was moms Lantus as the nurse did all my moms meds and was ready to leave I said “my mom needs her Lantus” and she looked at the screen and then her cart and said she would be back and I could see panic on her face. These meds were new to me so I had to make sure the roommate wasn’t in danger so I did tell the overnight head NP and told the roommates family the next day so they could look into it further.
Mistakes happen - we are all human but I knew I had to report it so that even additional training and protocols could be looked at.

Again - I am deeply sorry for your loss and now having this weigh on you - but I do think it’s best that it is reported and maybe it can help a new protocol be placed. Hugs
Calgirl Aug 2021
Wow. Good thing you were in the room at the time. So scary.
JoAnn29 Aug 2021
So sorry about ur Dad.

Yes, you should file a complaint to Medicare and the Ombudsman. This is serious. I have never received Meds from a Rehab. I was given ointment but given prescriptions to have filled when I got home. Most of the time I didn't need a prescription because I still had pills at home.

After caring for my Mom and some things that have personally happened with my DH, I don't think I would get anything new pill wise that a hospital or rehab recommends, till I talked to my PCP. I will no longer wait the "week or two" they suggest on the discharge papers to see ur PCP. Why, because hospitals do not consult with ur PCP the person who knows you. Knows ur background.
Calgirl Aug 2021
Thanks for weighing in here. Although my dad went in there with a med list he himself had been keeping up to date (with my help), he had faith in these people that he should take what they gave him, and we both saw they were communicating with the PCP. You'd think that would be enough, right?! Nope, not when we were both too tired and I was fried and had lost brain cells.
GardenArtist Aug 2021
Your post is heartbreaking.   I don't think I could be so controlled, and probably would be furious, angry and sadder than I could imagine.   You are a very compassionate person,  as well as logical.  And you're on the right track; this needs to be addressed, at multiple levels.

1.    Is this by any chance one of the chain rehabs?  If so, look up the corporate HQ.  If you need assistance with this, PM me and I'll help, so you don't have to reveal the name of the rehab company.

You can also check the state corporation records to get more background on the rehab itself as well as any owners who should be notified.   At the last legal job I had, it was apparent from clients that more and  more LLCs were investing in medical facilities at various levels.  

If an LLC owned this rehab, the participants are likely going to eventually lose some of their investment, sooner or later as the error translates into less patients.  It's not inappropriate to notify them, anonymously if you feel more comfortable.   Their ROI isn't your concern, but the partners need to be aware of the rehab's facility's mistake.   I wouldn't want to invest in a facility that experienced such a tragic mistake.

2.    I would also report to the local or state ombudsperson.   

3.   Was he placed in rehab directly from a hospital?  If so, the hospital administrator as well as the discharge planner, or whoever recommended this rehab, need to be notified.   The hospital might have to consider removing it from a recommended list.

4.   If someone else, or some type of agency or something similar recommended the rehab place, they also should be notified.

5.   I also agree that the State Medical Board should be notified.

6.   I don't know if this would be in line with how medical supervising agencies might handle it, but I don't think it's out of line to request an immediate review of medication procedures at the rehab.  This may NOT have been the first time it happened.

7.    Personally, I would also do a legal search of local (county) as well as higher level court dockets to determine if any malpractice cases have been filed.   This isn't to suggest you should do file suit as you've stated that's not your goal, but if this isn't the first time, there should be a more extensive level review initiated ASAP.

Your post brought tears to my eyes; this is so sad.
Calgirl Aug 2021
Thanks for this extensive list.
Yes, this is a smaller-chain rehab I think, and an LLC. I'll PM you the name. And yes, he came there directly from our local community hospital. This place was on the less-recommended end of their list of recommended facilities.
And yes, I WAS furious, angry and sad... It was quite the meltdown. Not to mention my own guilt about how I'd let it slip through too, etc. This came at a time when I had already lost too much sleep and could barely function, and the first home care alleged 4-hour shift had started. I'd gotten a call before the caregiver showed up informing me "We're sorry, she can only stay an hour." What a cluster.
NYDaughterInLaw Aug 2021
There are multiple failures here. The rehab facility sent your dad home with another patient's medication. The home care RN included the wrong med on his med list. And then you ended up giving him the wrong medication because two healthcare professionals screwed up and weren't paying attention. Do you still have the other patient's medication? If so, take a picture of the label and include it in a written letter to both the rehab facility and the home care agency. You should cc your state board of health and your state's Medicare Beneficiary Ombudsman. This is the only way to improve patient safety. The only way. Yes, heads may roll at both places but a medication error is one of the biggest mistakes and most preventable.
Calgirl Aug 2021
Yes, I've got the other patient's medication, right here in the evidence locker at home as it were. Today I'm picking up my photo prints of it. And off they will go in letters. Thanks!
AnnReid Aug 2021
Heartbroken for you.

If you were to report this to a state or local medical board, could you do so anonymously? Would there be some other agency that would be responsible for this sort of error?

Since you don’t want to seek reparations, my preference would be anonymity because that way the person who was traced to the error could be addressed with no previous sentiments about your dad getting in the way, and you yourself could stay in the background.

If your dad was loved by the staff, I’m sure he must have been a great guy. Hoping you will be able to potentially save someone else from his experience.

Hugs and Blessings.
Calgirl Aug 2021
I'm starting with anonymity for sure. I've already been through hell and just want to hide for a while. Strangely enough, my dad was one of the few residents who could speak out and think straight, at least for a while. So he was able to give really good critiques of the staff and the care, etc. I'll always remember the social worker there who sat down with us to listen to him and started asking him about more and more things because she knew she had a good reporter, haha!!
Thank you.
Isthisrealyreal Aug 2021
You should file a complaint with Medicare.

This type of negligence is dangerous and something needs to get their attention.

I am so sorry for your loss.

May God give you grieving mercies and comfort during this difficult time.
Calgirl Aug 2021
Thank you for your kindness. I'm starting today to do the reporting to various people.

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