Assisted Living Facility Failed to Properly Give Medications to Any Patients

When one caring son checked his elderly mother into an assisted living facility she was able to carry on a conversation, walk with assistance and go on day trips. Two months later the 79 year old woman was admitted to the hospital. She was covered in bed sores (also known as pressure ulcers, or decubitus ulcers), and hospital nurses said it appeared she had been lying in urine-soaked garments for days. Before she went to the assisted living facility her dementia had been controlled by medications, but now she was combative and disoriented. Her blood pressure was irregular and a wound on her back that had been managed with regular care had become severely infected. She was also dehydrated, and her weight had dropped by about 20 percent to 102 pounds.

His mother left the assisted living facility about two weeks ago and is recovering at a different facility. She was apparently one of many patients who were not receiving their medication. State officials on Tuesday placed a temporary ban on admissions at the 150-bed facility until officials there can ensure that residents receive their drugs. Patient record reviews by state authorities found that of 32 patients whose folders were checked at random, not one had received his or her medicines for the month, suggesting that perhaps no patients received the medications they needed for months.

The daughter of another resident at the facility found a plastic bag containing several months of her mother’s medications in a dresser drawer. She asked the staff about the medication and was told, incorrectly, that she was a “self medicator,” according to the complaint filed with the state.

State officials started investigating the assisted living facility after receiving complaints in September. During the investigation, the facility’s wellness director told investigators that she knew caregivers were not administering drugs to residents and that some were throwing the medications away because they did not have time to administer them, officials said. Other staff members told state officials this was common at the facility.

Staff reported to the state that almost every resident was missing one or more medications. In response, the facility’s executive director said arrangements would be made with a pharmacy to correct the problem.

Additional complaints were received by the state in October, and a second investigation revealed that again all residents sampled were not receiving their medications as prescribed, state officials said. The facility has since hired two registered nurses and a consultant to correct the problems. The executive director has resigned and been reported to her licensing board, officials said.

The state officials say the facility appears to be correcting the problems. If the situation is not rectified, the state could appoint a temporary manager of the facility, or suspend or revoke its license.

The former wellness director, who worked at the facility in the summer, said the facility employed only one technician to administer medications for 110 residents. She said she often received calls from doctors, wondering why the lab results of their patients were not reflecting medications. Sometimes technicians initialed records as if medication had been administered when it had not. She also said when it became clear that her boss would not help rectify the problems, she quit and filed a complaint with the state. For more, read the story.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.

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