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IOWA FINES STATE VETERANS' HOME $10,000 -- An aide was

fired for dispensing medications while under the influence of

drugs and stands accused of stealing the veterans' medicine

to finance methamphetamine and marijuana habits.

 

 

Story here... http://desmoinesregister.
com/apps/pbcs.dll/article?AID=/20
070909/NEWS10/70909034
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State fines veterans home $10,000

Drug thefts, hundreds of medication errors are alleged

By CLARK KAUFFMAN
REGISTER STAFF WRITER

The Iowa Veterans Home in Marshalltown faces a $10,000 fine over hundreds of alleged medication errors and the reported theft of painkillers and other drugs intended for veterans.

State records also show that an aide at the state-run facility was fired this summer for dispensing medications while she was under the influence of drugs. She also was accused of stealing the veterans' medicine to finance her own use of methamphetamine and marijuana, according to state records.

Dan Steen, the care center's commandant, said he is appealing the $10,000 fine imposed by the Iowa Department of Inspections and Appeals.

He said he is confident the appeal will result in "the truth" coming out, and he questioned the decision by state inspectors to levy a large fine against a government-run facility that provides care for 700 veterans.

"We just cause these homes to become deeper in the hole," Steen said. "If a home has done something wrong and there is a fine, you know, those are dollars that could have bought electric lifts or other equipment."

According to the inspections department, the Iowa Veterans Home has documented hundreds of medication errors at the facility this year. But because the facility has 700 residents, some of whom may receive a dozen medications daily, the overall error rate has remained well below the 5 percent limit imposed by federal officials.

Steen says the home's error rate is so low that it's "close to perfection" and is "unheard of" in the health care field.

"Our error rate here is 0.0176 of 1 percent," he said. "Now, you tell me what nursing home and what hospital would have that low of a medication error rate."

"Immediate jeopardy"

In July, however, state inspectors visited the Iowa Veterans Home, reviewed its medication policies and practices, and declared that veterans there were in "immediate jeopardy." Within hours, the home changed its medication policies.

The inspectors' report alleges that on June 28, the staff gave one veteran 10 medications that were to be administered to another, much heavier resident. The veteran initially refused some of the drugs, which included anti-psychotic drugs and medications for seizures, but he ultimately accepted them.

After the error was discovered, a doctor at the home told workers to monitor the veteran through the night. A few hours later, the man turned red and became incontinent and unresponsive, with his tongue protruding from his mouth.

The doctor initially wanted to keep the man at the facility but within a half-hour decided to have him taken by ambulance to a hospital.

At the hospital, a breathing tube was inserted, and the veteran was moved to the hospital's intensive care unit. About eight hours later, he showed the first signs of becoming responsive. He was discharged from the hospital two days later and was returned to the Iowa Veterans Home.

Allegations of errors

The worker who mistakenly administered the drugs allegedly told inspectors that after giving residents their drugs, employees would typically sign paperwork indicating the drugs had been given as ordered, but they did so without reading those orders.

She also reportedly told inspectors she should have her own license revoked for "making a whole lot of mistakes" with residents' medication.

Among the state's other allegations:

- One resident was mistakenly given methadone and four other drugs. He then became shaky and his breathing slowed, resulting in hourly checks by employees. That same day, a different resident was mistakenly given at least four drugs that should have gone to another veteran. That triggered a need for regular checks of the man's blood pressure.

- While inspectors watched, a worker committed two errors in dispensing one veteran's medication. An hour later, the same worker tried to give a different resident two pills. The resident objected, saying he was to receive three pills in accordance with his doctor's orders. The worker insisted that only two pills were to be given, but when the resident continued to object, the worker then checked the resident's paperwork and realized the man was correct in stating that three pills were to be given.

- Five diabetic residents were victims of errors involving their insulin. They did not receive their insulin, received someone else's medication or received the wrong dose of insulin.

- During the first three months of the year, the staff allegedly identified more than 200 medication errors. The home's quality assurance committee met periodically and discussed the errors but "failed to implement new approaches" to improve the situation, a state report said.

The state inspectors also allege that no physicians attended the staff's quality assurance meetings between January and May of this year.

Steen said the home's medical director, Dr. Melissa Bruhl, attended those meetings, but Bruhl said the inspectors might be correct. At most, she said, she attended one of the meetings.

The home's formal, written response to the state inspectors' allegation says only that "federal law does not require the medical director to be in attendance at the QA meetings."

Worker admits drug use

Earlier this year, the veterans home began investigating allegations that one of its medication aides, Jennifer Huston, was stealing morphine, oxycotin and other drugs from veterans and trading the substances for methamphetamine that she was using.

At a recent public hearing where she sought unemployment benefits, Huston admitted using meth and marijuana during her years of employment at the Marshalltown facility. But she denied stealing residents' medication, and she denied ever being high at work.

Two of her co-workers, Tachelle Thomas and Lidia Avalos, told administrators at the home that Huston admitted to being high at work. According to transcripts of their interviews with the administrators, Thomas reported that Huston claimed to be high one day as she reported for work.

"Two days after that, she was high again," Thomas alleged.

Avalos made a similar allegation, saying Huston "would just tell me that she would come in high to work, and she would say, 'Didn't you ever notice?' And I would say, 'Yeah, but I didn't say nothing.' "

Avalos also alleged that Huston "would throw a fit" if she was not allowed to work the medication cart while on duty.

According to state records, a third employee, Lauren Barth, told Iowa Veterans Home administrators that Huston would approach her at the start of a shift when Barth was scheduled to work the medication cart and say, "How much do you love me? Will you let me be on the med cart?"

State's report disputed

The care center's personnel records show that Huston was fired for working while "under the influence of mood-altering substances that were illegal."

Nursing supervisor Penny Cutler-Burmudez testified under oath at a hearing on Huston's dismissal that Huston was fired for "being under the influence while passing medication to the residents."

Still, Steen, the commandant, insisted there is no evidence Huston was ever high while on the job. He says she was fired for admitted drug use during her time of employment at the Iowa Veterans Home.

When asked about his staff's sworn testimony and the home's personnel records, some of which he signed, Steen said, "I'm not aware we had any indication of her being under the influence of drugs while at work."

Steen questions the truthfulness of the state inspection report and said he has no way to verify the comments state inspectors have attributed to his employees.

"There are tapes we've asked for so that we can determine this is what these people really said and, you know, it's not being given to us," Steen said. "That seems kind of strange to me."

Asked about the change in medication policies after state inspectors said that veterans were in "immediate jeopardy," Bruhl, the facility's medical director, said that's an indicator of how quickly the home responded to resident needs.

"I tend to look at the positive side of this," Bruhl said. "A change that needed to occur for the safety of the residents happened immediately."

Reporter Clark Kauffman can be reached at (515) 284-8233 or ckauffman@dmreg.com

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Larry Scott  --