Medication Errors May Indicate Elder Abuse

spoon with pills

The federal government fined a nursing home in New York State almost $50,000 for incorrectly administering insulin injections to a resident.  The hefty fine indicates medication errors were more than a mistake, but rather elder abuse. 

Medication Errors at Humboldt House Rehabilitation and Nursing Center

Investigators from the New York State Health Department concluded that the workers at Humboldt House Rehabilitation and Nursing Center caused “actual harm” to a resident when they inappropriately administered insulin.  The Centers for Medicare and Medicaid Services (CMS) imposed a hefty fine on the facility which was the 6th largest fine levied in the state in 2018. 

In February 2018, the woman was taken to a local hospital after she was found unresponsive in her room.  Knowing she was a diabetic, the staff members revived her with medication and fruit juice before referring her to the hospital for a higher level of medical care. 

She returned to the nursing home after a short hospital stay.  Apparently, the patient’s discharge report from the hospital read “PLEASE AVOID GIVING THIS PATIENT INSULIN,” in capital letters.  Knowing the patient was headed back into the care of an assisted living facility, it is a reasonable assumption that the message was addressed specifically to the Humboldt House medical staff. 

Despite the very clear discharge summary, the state Health Department inspection report showed that the nursing home’s medical director, a physician, signed the order to administer insulin to the woman.

Medication Errors May be a Form of Elder Abuse or Neglect

In the wake of the fine and bad publicity, the nursing home officials say they have updated their training protocols about glucose testing for diabetic patients.  Humboldt House has the lowest possible rating given by CMS: a one-star overall rating, which means its facilities are “much below average.”

Ultimately, the responsibility for prescribing the insulin should rest with the physician who signed the order.  The doctor in question, the nursing home’s medical director, blamed a nurse for inaccurately reading him the discharge summary from the hospital.  Asserting that he “usually” reads the reports himself, the prescribing doctor said he “didn’t know” why he failed to read the discharge summary himself, relying instead on a nurse to read the information aloud to him.  The nurse was subsequently disciplined. 

The director of nursing at the facility shot back, “The doctor should have looked at the discharge summary.  It is expected the doctors read the discharge summary.”

Regardless, shifting blame does not erase the harm that the patient suffered as a result of what can only be described as elder abuse or neglect.  The CMS fine highlighted how seriously the federal agency considered this failure of care to be. 

Medication Errors and Elder Abuse

Elder abuse need not be overt, malicious abuse.  Often, it is difficult to detect as it comes in the form of negligence which is all the more insidious.  Medication errors are prevalent in nursing homes because the residents are by and large elderly and in poor health.  Almost every nursing home resident will have an individual medication routine, involving perhaps several different medications, which the care staff must observe. 

Medication errors fall into two categories which are both forms of elder abuse.  Some errors are simply that – careless mistakes.  Mistakes are caused by negligence, be it inadequate training, not paying attention, or not following the patient’s care plan.  Other medication errors include the intentional misuse of drugs to subdue disorderly patients, also known as chemical restraints. 

Careless Errors

Most common in facilities that employ insufficient numbers of staff members, these types of errors are generally mix-ups in which a patient may:

  • Receive another resident’s medication
  • Receive the wrong dose of their own medication
  • Miss doses of their medication

Many nursing home residents are in a fragile state of health and depend on their medications.  There is no excuse for errors of this type. Though some are unintentional, they are negligent, and therefore are elder abuse.

Chemical Restraints

Infinitely more disturbing than an unintentional mistake is the tragically widespread phenomenon of chemical restraint.  This practice is the off-label use of anti-psychotic medications on patients who have no clinical reason to take them.  The intended effect is a docile patient without irritability or wandering that nursing home residents are prone to exhibit. 

Of course, this practice is illegal, but it happens frequently.  An analysis from the U.S.  Government Accountability Office (GAO) showed that 179,000 nursing home patients are inappropriately and illegally subject to chemical restraint each week in nursing homes.  About 15,000 patients die every year from the illegal use of antipsychotics. 

Know The Signs of Medication-related Elder Abuse

Sadly, many nursing home residents are unable or unwilling to report incidents of neglect, mistakes, or outright abuse in nursing homes.  Consequently, there is a need for family members to be present and alert for signs that their loved one may be suffering. 

A sharp downturn in health is clear sign something isn’t right in your loved one’s nursing home.  It is often an early indication of elder abuse. 

With regard to medication errors specifically, it’s a good idea to try to be present at a time when your loved one should receive medication.  It is an easy and non-confrontational way of checking up on your loved one’s care.  If you have any concerns about medication administration, or suspicions of elder abuse, seek medical attention for your loved one. 

Medication errors have signs that can be easily confused with the progression of dementia or other cognitive decline. The sudden appearance of some of the following is cause for concern:

  • Unusual fatigue, exhaustion, and disorientation
  • Suddenly withdrawn behavior during visits
  • New and unexplained side effects
  • Sleeping an unusual amount
  • Zoned-out, sedated behavior

The side effects of a wrong medication, wrong dosage, or taking a medication not prescribed to you can be devastating.  Medication errors can lead to serious adverse events, and in some cases, can be life-threatening. 

Get Help with Elder Abuse Concerns

If you suspect that your loved one is a victim of elder abuse, you should talk to an experienced nursing home abuse attorney right away.  Medication errors may be an honest mistake, but in the medical field, such mistakes are called malpractice. In any healthcare setting, malpractice is simply unacceptable.

At Nursing Home Abuse Center, we can help you sort through your loved one’s experience.  We can help you determine if he or she is a victim of elder abuse.  If so, we will help decide what steps to take next.  Get help with your concerns by scheduling a free consultation with one of our legal professionals.   

Call 1-800-516-4783 now to schedule a time to consult with an attorney or contact us online. 


meagan cline

Written By Meagan Cline

Meagan Cline is a professional legal researcher and writer. She lends her expertise to FNHA and our websites, including Birth Injury Guide and