Prescription for danger: Medication errors inside nursing homes lead to hospitalization, death

(WXYZ) - Roy Rach was supposed to spend just a few days at St. Joseph's Caretel Inn. 

In the winter of 2011, the 81-year-old had gotten out of the hospital after being treated for an abnormal heartbeat.  Doctors prescribed him a few days of rehab.

"He was alert and happy when he went in there," remembers his daughter Karen Rach.

"And how did he leave?" Channel 7's Ross Jones asked.

"He left in a stretcher in a diabetic coma," she responded.

Karen remembers standing over her father's hospital bed, hoping he'd wake up.  But at Caretel, according to state records, his diabetes had gone untreated. 

"We were hoping we'd be able to get a chance to talk to him again," Karen recalls.

Her father died just days after Thanksgiving.  His family says a hospital helped saved his life, but his nursing home ended it.

Attorney Jules Olsman has spent more than 25 years exposing nursing home neglect.. He says this is just one of the latest examples.

"If what happened here happened in a childcare setting, they'd arrest the people involved," Olsman said.

Rach's glucose level was a normal 116 when he came to Caretel, but by the time he left--only 5 days later--it was nearly 6 times that. Olsman, who's preparing a lawsuit against the company, said Rach's diabetes went untreated until his fifth day at Caretel, even though records show that staff knew he was diabetic.

"It'd be like a fire truck pulling up in front of a burning building, stopping and looking at it, and keeping going.  Same thing," Olsman said.

Caretel officials declined comment on Rach's case, but said patient care is their highest priority.

"Lack of physician involvement, lack of staff, lack of training. That's why you have consequences like this," Olsman said.

In Michigan nursing homes, significant medication errors are all too common.  Data shows some patients have received too much, not enough, or the wrong medicine altogether.

Over the last 3 years, federal records show 144 significant medication errors have been detected by investigators. 

At Warren's Autumn Woods Healthcare, a patient wasn't given necessary eye drops for 4 days, then went blind in her left eye. A resident at Livonia's Autumnwood facility was given penicillin even though staff was told that the patient was allergic.

Brighton's Caretel Inn was home to Emeline Falls.  A nurse gave her 10 milligrams of Glyburide, a diabetes medicine, that was prescribed for her  roommate. Emeline went into hypoglycemic brain failure and died. 

At the Clarkston Specialty Healthcare Center, an 85-year-old resident went into septic shock after nurses failed to give her prescribed antibiotics. She developed a severe urinary tract infection and later died.

"There's no way reasonably that a nurse or a doctor or anybody in that nursing home should have been missing that medication, those two medications. That should have been given," said Dr. Shaun Jayakar a geriatric physician with St. John Providence Health System.

Gail Clarkson is in charge of compliance for all 15 Medilodge  nursing homes in Michigan. The facilities have garnered scores of awards. but , over the last 3 years, they've also been cited 10 times for significant medication errors.

"It's important, very important to us that our residents receive the ultimate in care," Clarkson said.

At its Milford location, the director of nursing told an investigator "it was a mistake" when an 86-year-old didn't get her vital heart medication. 

Medilodge's Rochester Hills facility was cited for giving a patient someone else's powerful narcotics, even after he complained: "I got the wrong medication."

But the nurse didn't listen, according to a state report.   The patient says she "blew me off and said that the doctor had changed my medication orders."

"I mean these are not small errors. These are, in some cases, critical medications that these patients need to survive," Jones said.

"Any error concerns me," Clarkson replied.

In Medilodge's Taylor facility, a 68-year-old woman went 8 days without receiving any of the 11 medications her doctor prescribed to treat her heart condition and diabetes.  The facility only realized this when the woman's daughter brought it to their attention.

"Well, her daughter would notice.  She knows her mom better than anyone else," Clarkson said.

 "Shouldn't the facility be monitoring this more closely than her daughter though?" Jones asked.

"The facility should certainly be monitoring to make sure they don't have medication errors," Clarkson responded.

She insists these errors aren't caused by understaffing or overworking.  At the end of the day, Clarkson says, some mistakes can't be avoided. 

"For those thinking about putting a loved one in a nursing home or a place like this, what sort of assurance can you offer them that that won't happen?" Jones asked.

"Personally? I can't offer them the assurance. I've been a nurse since 1968, and unfortunately medication errors occur in hospitals, in clinics, in home health, and people give themselves the wrong medication," Clarkson said.

Attorney Jules Olsman says families should expect better.

"It's not okay to say, 'Well, people make mistakes. That's the way it is,' " he said

"When it's your mother or your father, that is not an acceptable excuse for abominable medical care."

Except for Medilodge, the nursing homes mentioned in our report declined to appear on camera or did not return our calls.

Contact Investigator Ross Jones at or at (248) 827-9466.

The list of all the Michigan facilities cited for significant medication errors over the last 3 years can be found below:

Facilities cited for medication errors

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