A resident at a nursing home in Buffalo, Minn., did not receive her newly prescribed potassium-replacement medication, an oversight connected to her death in January 2010, a state investigation concluded.
The findings by the state Health Department, released this week, determined that Lake Ridge Care Center provided "inadequate medication administration."
The investigation also found mishandling of other medications for the woman and for several other residents at the home in late January and early February of the same year.
Two unannounced visits by state investigators in June 2010 found that the home was back in compliance with regulatory requirements.
According to the report:
The woman entered Lake Ridge on Jan. 14, 2010, with diagnoses of congestive heart failure and low potassium. Her doctor's orders that day called for her to receive three two-tablet doses of potassium a day. In all, the woman missed 26 of those doses over more than eight days.
She was sent to the emergency room on Jan. 23 for an "unresponsive episode." While there, she suffered a severely abnormal heart rhythm and died early that afternoon.
Her potassium level was found to be extremely low when tested in the emergency room. Potassium helps to keep blood pumping through the heart. Her official cause of death was ruled cardiac arrest.
The investigation attributed the medication errors, which were not detected until after the woman died, on "transcription errors."
As is practice, information released to the public in this investigation did not include the name of the resident.
Paul Walsh • 612-673-4482