Springfield nursing home investigation: Patient ODs on unlocked pills

Updated Feb 16, 2018

Two patients allegedly gained access to unsecured narcotics and one of them overdosed at a Springfield nursing home, according to state documents obtained by the Springfield News-Sun.

The Ohio Department of Health filed a statement of deficiencies for Eaglewood Care Center, 2000 Villa Road in Springfield, after the alleged incident that occurred in December.

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Two Eaglewood residents allegedly took oxycodone pills from a narcotic box left unlocked on a medication cart by a licensed practical nurse on Dec. 10, according to the Ohio Department of Health statement of deficiencies.

“… The facility failed to ensure medications were properly secured and supervised,” the records say. “This resulted in immediate jeopardy, serious life-threatening harm for one cognitively intact resident with a history of drug abuse …”

Eaglewood staff declined to comment to the Springfield News-Sun. Wallick Properties Inc., listed as the operator on the state health department’s website, didn’t return calls seeking comment.

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A nurse discovered on Dec. 10 that 23 oxycodone pills were missing from the skilled nursing unit’s medication cart, according to the report. Eaglewood began an investigation immediately, the documents say, and an empty medication sleeve was found in a patient’s trash.

Another patient was acting unusually lethargic, the documents say, and was sent to the hospital.

“Upon return from the hospital that same day on Dec. 10, 2017, Resident No. 8 came forward and confessed that he was involved in distracting the nurse in order for Resident. No. 1 to pull the medication from the drawer of the medication cart,” the report says.

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Resident No. 1 allegedly consumed a suspected 19 pain pills, the statement of deficiencies says, suffering an overdose that required treatment with Narcan twice and hospitalization until Dec. 29. Resident No. 8 allegedly took four of the pills.

An interview with one of the nurses, “revealed that the bottom drawer of the back hall skilled unit medication cart did not always close all the way,” the documents say. “She revealed if you did not push that bottom drawer in all the way, it would still look like the cart was locked. However, the cart would not be locked as the lock was able to be pulled back out. Registered Nurse No. 10 also revealed she had told her unit manager in passing about this concern but there was never a formal report made.”

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The nurse who allegedly didn’t secure the cart properly allegedly told investigators that she didn’t get any orientation and wasn’t told about how to work the medication cart.

“(She) stated that if she would have known about it she would have made sure to lock it properly,” the documents say.

Eaglewood had 70 patients at the time of the alleged incident, with a capacity for 99 patients, according to the documents.

The state health department interviewed staff members, law enforcement and reviewed records as part of its investigation, the documents say.

The nursing home took several corrective actions, the report says, including:

• Educating nursing staff on medication cart security and making sure all are properly secured.

• Completing a medication cart functionality assessment, which showed both carts in the affected area were in working order. It was noted that a narcotics box on one of the carts was unable to lock securely when slid to the front of the cart.

• Initiating medication cart lock audits one to two times per day, five days per week.

• Educating the nursing staff on the facility’s malfunctioning equipment protocol.

• Assessing the medication carts again on Dec. 27 and changing the keys on them, allowing the narcotics boxes to lock securely.

• Implementing a monthly preventative maintenance schedule on the medication carts.

The facility has provided a plan of correction to prevent a similar incident in the future, the Ohio Department of Health documents say.

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The statements made in the plan of correction aren’t an admission to any of the deficiencies alleged by the report, the document says.

Once a plan of correction is reviewed, the state will conduct a follow-up survey, ODH spokeswoman Melanie Amato said.

Any possible penalties or fines won’t be decided on until after that follow-up visit, she said.

Fines are rare, Amato said. If a care center corrects the problems and other issues aren’t found during the follow up inspection, a nursing home typically goes back to operating as normal.