Both incidents occurred within 48 hours in July 2024 at Aventura at Terrace View, where a separate case involving delayed lab work led to a resident's cardiac arrest and emergency intubation.
The insulin error happened during morning medication rounds on July 8. Employee 2, a licensed practical nurse from a staffing agency, had prepared insulin for two residents on her medication cart. One pen contained 6 units of Lantus insulin for Resident A3, who had diabetes and lived on the locked dementia unit. The other was a syringe containing 20 units for a different resident.
"I mistakenly grabbed the syringe (containing 20 units of Lantus insulin) and brought it to Resident A3's room," Employee 2 wrote in her witness statement. "I administered 12 units of the 20 units into the right lower abdomen before I realized it was the wrong dose."
Resident A3 received double his prescribed insulin dose. Staff monitored his blood glucose levels throughout the day, which dropped as low as 78 mg/dl by mid-afternoon before climbing back to normal ranges by evening.
Two days later, Employee 1, another agency LPN, administered the wrong medications entirely to Resident A1, also a dementia patient on the locked unit.
Employee 1 gave Resident A1 the medications prescribed for a different resident. These included Eliquis, a blood thinner; Amlodipine for high blood pressure; Donepezil for Alzheimer's disease; and Depakote, an anti-seizure medication with a special enteric coating designed to prevent dissolution in the stomach.
Employee 1 crushed all the medications and mixed them in chocolate milk, which Resident A1 drank. The pharmacy had placed a sticker on the Depakote specifically instructing staff to "take the medication whole, do not crush."
"I was passing out medications and I gave medicine to the wrong resident," Employee 1 stated in her witness report dated July 10.
The facility's medication incident report provided no documentation of which medications were administered in error or how much of the chocolate milk the resident consumed.
During an interview on July 31, the assistant Director of Nursing confirmed both medication errors occurred and resulted in significant harm to residents.
But the most serious case involved delayed laboratory work that led to a medical crisis.
Resident A5, who had severe dementia and chronic kidney disease, developed swelling in both lower legs. His physician ordered blood work on a specific date to check his basic metabolic panel, including potassium levels, due to concerns about blood clots given his history of taking blood thinners.
The lab results showed his potassium level was elevated at 5.6 mmol/L, flagged as high on the report. Normal levels range from 3.5 to 5.1. The physician immediately ordered a repeat potassium test.
Staff attempted to draw blood the next morning at 6 AM, but Resident A5 refused. A nurse documented the refusal but made no attempt to reapproach the resident or implement his care plan, which specifically addressed his tendency to refuse medical care.
"Resident will be informed of risk vs. benefits of non-compliance," the care plan stated. "Resident will be offered appropriate alternatives when possible."
Nobody told the physician about the refusal.
"She had informed the facility to contact her with any resident refusals, but they never did regarding the failure to repeat the lab work," the physician told inspectors during an interview. She said she was concerned that the resident "does not understand, and cannot make an informed decision, and that he must be reapproached after the initial refusal."
Seven days passed. The assistant Director of Nursing couldn't explain why the potassium level wasn't drawn during that time.
When blood was finally drawn, the resident's potassium remained elevated at 5.4 mmol/L, still flagged as high.
That same day at 3:45 PM, staff found Resident A5 sitting in a chair outside his room with a blank stare. His vital signs were alarming: temperature 94.1 degrees, pulse 5 beats per minute, blood pressure dangerously low, oxygen saturation 90 percent. His lung sounds were diminished and he showed slight right-sided weakness.
Staff called the physician and sent him to the hospital immediately.
Upon arrival at the emergency room, Resident A5 was hypotensive and bradycardic. His potassium level had climbed to 6.1, a critically high level. He had developed metabolic acidosis and acute kidney failure. Hospital staff gave him nearly three liters of fluid and started him on Levophed to support his blood pressure.
When laid flat, he became cyanotic. Doctors intubated him and transferred him to intensive care for septic shock. He went into cardiac arrest in the ICU. CPR was performed for three minutes before he was revived.
"The delay in obtaining this labwork placed this resident in a medical crisis and subsequently he suffered a cardiac arrest with a critically high potassium level in the ER," his physician told inspectors.
The facility also failed to follow its own dietary policies. Two residents with physician orders for double portions received single portions instead. Resident 72, who had Alzheimer's dementia, told staff he was still hungry after finishing his meal and requested another one. The dietary manager confirmed both residents should have received double portions as ordered.
Another resident with a physician order for chopped food received whole hamburgers instead. The Food Service Manager said "she always gets her hamburgers that way, her brother does not want her to have chopped food," but couldn't provide any documentation that the resident could safely consume whole foods.
The facility's infection control program showed similar gaps. Staff tracked outbreaks of influenza A and B affecting 8 residents in March and April 2024, plus 6 cases of RSV and 27 residents with gastrointestinal symptoms. The logs noted "3 cases of employee flu, confirmed and 1 symptomatic employee, not confirmed" but provided no documentation of staff infections in official tracking logs.
As of June 14, the facility hadn't started tracking infections for June. There was no documentation of staff or resident education following the respiratory and GI outbreaks, no evaluation of interventions to prevent spread, and no trending analysis to identify patterns.
The Infection Preventionist confirmed the facility "was unable to demonstrate a fully functioning comprehensive program to monitor and prevent infections."
Physical conditions added to the problems. The men's locked dementia unit housed 24 residents in a single dining room measuring 576 square feet. Nine dining tables, gaming machines, and chairs crowded the space. Several residents had difficulty maneuvering wheelchairs around each other during meals.
"It was a tight fit in the room during meals," the interim Director of Nursing confirmed. The room served as the only dining and activity space for residents who never leave the locked unit.
Outside, cardboard overflowed from dumpsters while broken equipment cluttered the refuse area. Inside the D-unit dining room, inspectors found a dead decomposing mouse stuck to a glue trap in a cabinet under the sink. Yellow substance was smeared on the cabinet floor alongside what appeared to be rodent droppings, debris, and dead bugs.
The administrator confirmed the pest management company had visited just days before to address mice activity, but staff had failed to check and remove dead rodents from traps.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aventura At Terrace View from 2024-06-14 including all violations, facility responses, and corrective action plans.