The medication errors at Aventura at Terrace View occurred within 48 hours of each other in July 2024, according to a federal inspection report. Both incidents involved agency nurses working on the facility's locked dementia unit.
On July 8, Employee 2, a licensed practical nurse from a staffing agency, prepared insulin for two residents during morning medication rounds. She drew up 6 units of Lantus insulin in a pen for one resident and 20 units in a syringe for another.
"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."
The resident received twice the prescribed amount of long-acting insulin. Blood glucose monitoring throughout the day showed levels dropping from 106 mg/dl at 8:03 a.m. to 78 mg/dl by mid-afternoon, though they recovered by evening.
Two days later, another agency nurse made an even more dangerous error.
Employee 1, also an agency LPN, gave Resident A1 medications prescribed for a different resident. The wrong medications included Eliquis, a blood thinner; Amlodipine for high blood pressure; Donepezil for Alzheimer's disease; and Depakote, an anti-seizure medication with a special coating.
The nurse crushed all the medications and mixed them into chocolate milk.
The Depakote was a delayed-release tablet specifically designed to bypass the stomach and dissolve in the intestines. The pharmacy had placed a warning sticker on the medication card stating "take whole, do not crush." Crushing the enteric-coated tablet destroys its protective mechanism and can cause stomach irritation or reduce effectiveness.
"I was passing out medications and I gave medicine to the wrong resident," Employee 1 stated in her witness statement.
The facility's medication incident report provided no details about which medications were given incorrectly or how much of the chocolate milk the resident consumed.
Neither nurse appeared to follow basic medication safety protocols, such as checking patient identification before administering drugs.
The Assistant Director of Nursing confirmed during a July 31 interview that both employees had administered incorrect medications, resulting in significant medication errors.
But medication mistakes weren't the only safety failures inspectors found.
A resident with severe dementia and chronic kidney disease nearly died after staff failed to communicate critical lab results to his physician and delayed follow-up blood work for a week.
The resident had elevated potassium levels at 5.6 mmol/L, well above the normal range. High potassium can cause dangerous heart rhythm abnormalities.
His physician immediately ordered repeat blood work to monitor the dangerous level. But when staff tried to draw blood the next morning, the resident refused.
"Resident A5 refused to have the repeat bloodwork drawn to obtain the potassium level this AM," a nurse noted. No one attempted to approach the resident again or implemented his care plan strategies for dealing with refusals.
More critically, no one 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 inspection report states.
The physician told inspectors she was never notified that the blood work wasn't completed. She emphasized that the resident, with severe cognitive impairment, couldn't make informed decisions about his medical care and should have been reapproached.
Seven days passed before staff finally obtained the repeat blood work. The potassium level remained dangerously high at 5.4 mmol/L.
Hours after those results came in, staff found the resident sitting outside his room with a blank stare. His temperature had dropped to 94.1 degrees, his pulse was extremely slow, and his oxygen levels were low. He showed signs of weakness and wasn't responding to commands well.
The facility sent him to the hospital immediately.
In the emergency room, his potassium level had climbed to 6.1, a critically high level. He arrived with low blood pressure and a dangerously slow heart rate. Doctors intubated him and transferred him to intensive care for septic shock.
He went into cardiac arrest in the ICU. Medical staff performed CPR for three minutes before reviving him.
"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 Assistant Director of Nursing told inspectors the resident "had the right to refuse treatment" but couldn't explain why the blood work wasn't obtained until seven days later or why the physician wasn't notified of the refusal.
Inspectors also discovered a decomposing mouse stuck to a glue trap inside a dining room cabinet on the dementia unit, surrounded by what appeared to be rodent droppings and debris. The facility's pest control company had reported mice activity in resident rooms and the dining area just days earlier, but staff had failed to check or clean the 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.