Growing old: Medication error, death point to problems
BY ZIVA BRANSTETTER World Projects Editor
Sunday, July 08, 2007
It was 6:35 a.m. when the
young nurse's aide -- distracted by blinking call lights, ringing phones and a heavy load of
patients at the Bixby assisted-
living center -- gave John Noland the wrong medication.
One day later, the 81-year-old church deacon was dead.
Noland had a history of
heart problems and the medication he was accidentally given at Sand Plum Assisted Living Center in Bixby almost
certainly caused his death, according to two medical experts who filed reports in a
The drug, Pletal, which is
used to treat leg pain, comes
with numerous warnings that
it could lead to death if given
to patients with a history of
heart problems, court records
Just days before he died on
July 12th, 2004, Noland was up
and around, driving a car, going to a Wal-Mart store and a
shopping mall, according to
testimony by an assisted-living
Noland grew up near Vinita,
married and raised three
daughters while working at
the Goodrich tire plant in Miami, Okla., said Patsy Lowe, a
As the Sunday school superintendent at Northwest Baptist Church, Noland made
sure everything at the small
church ran smoothly on Sunday mornings, she said.
''I've never seen a man that
was as loving toward his wife
and children as he was. He
was just a perfect man,'' Lowe
The civil lawsuit filed by Noland's family against the home
ended in a settlement last
year, records show. Court records do not show the amount
of the settlement.
A statement provided by
Sand Plum's attorney, Jeff
Glendening, states that the facility was not responsible for
It states the aide notified
Noland's doctor, who advised
the medication would not
harm Noland and that he did
not need to be hospitalized.
''While Sand Plum remains
firm that the incident did not
cause Mr. Noland's death,
there was nonetheless a mistake for which amends were
made with the family consistent with Sand Plum's mission
and purpose. Sand Plum remains dedicated to providing
the best care possible to its
Noland's death is an extreme example of what can
happen in assisted-living centers when aides fail to receive
adequate training or staffing is
Last year, state inspectors
wrote nearly 50 citations to 26
assisted-living centers in Oklahoma for medication errors,
inadequate training to give
medications and related issues, a Tulsa World analysis
Among those cases:
- At the Mustang Assisted
Living Center in Mustang,
aides did not give medicines
as ordered to five residents.
The facility told inspectors it
ran out of medicine the previous day.
- At Ten Oaks, a Merrill
Gardens Community in Lawton, the facility failed to keep
accurate medication records
for 12 out of 15 residents in the
dementia unit. By 4 p.m., aides
had filled out forms showing
they had already given the 8
p.m. medications to residents.
Some of the problems can
be attributed to overworked
aides. Oklahoma's staffing requirements do not dictate the
staff-to-patient ratio for aides.
''Each assisted-living center
shall provide or arrange qualified staff to administer medications based on the needs of
residents,'' the regulation
Medications must also be
reviewed monthly by a registered nurse or pharmacist and
unlicensed employees who administer medication must
complete a training program
approved by the Health Department.
According to documents
filed in the lawsuit by Noland's
family, two nurse's aides were
responsible for 70 patients at
Sand Plum between 11 p.m.
and 7 a.m.
Few assisted-living centers
have licensed practical nurses
or registered nurses on duty
at night, and state regulations
do not require them to do so.
Most only have aides.
Certified medication aides
receive about 24 hours of specialized classroom training before they can distribute medicine to patients.
The aide who gave Noland
the wrong medication apparently ''pre-set'' her medicines
for all residents instead of giving them out one at a time,
court records indicate.
Aides are trained not to use
such a procedure because it
increases the chance of a medication error.
''There was a lot going on
with call lights going off,
phones ringing that I got distracted,'' the aide wrote in an
A medication supervisor for
Sand Plum testifies in a deposition that turnover at the facility was high and aides worked
double shifts at times.
''Some days they'd get hired
and not even show up,'' the supervisor says in a deposition.
An inspection report states
Noland's death was not reported to the Health Department
because staff at the facility did
not consider it to be neglect.
The facility was cited in
March 2006 for failure to report neglect in Noland's death,
It was also cited for failure
to ensure staff members administer medication in a safe
John Noland (seated) poses for a family snapshot with his
wife, Jo, in 2003 during the couple’s 60th wedding