An elderly nursing home resident in Owatonna, Minn., was not given his crucial anxiety drug for 10 days -- then got 10 times the prescribed dosage and died the next day, according to a state investigation released this week.
The death of Herbert Drescher, 84, officially was blamed on chronic lung disease, but a doctor involved in the case told a state investigator that the overdose of lorazepam "may have been a factor" in the July death.
Reached Friday, family members said they were never notified of the medication errors or told that the death was under investigation.
"For heaven's sake, I didn't know that" he was given an overdose, said Velma Drescher, Herbert's widow, in an interview.
A nursing home official insisted Friday that the family was notified of the circumstances surrounding Drescher's death.
The case, disclosed in a report by the state Health Department, comes to light amid concern over medication errors at other long-term-care facilities in Minnesota and against a backdrop of frustration among advocates that abuse and substandard care often go undetected or unpunished.
State investigators concluded that the nursing home, Owatonna Care Center, was to blame for the medication missteps that preceded the death of Drescher, of Albert Lea. They noted that "26 omitted doses of the medication occurred with multiple employees over several days."
The overdose was not discovered by the nursing home until two days after Drescher was found in his bed and a nurse noted that he "must have died in his sleep," the state report added.
State investigators also found that some drugs were missing at the nursing home and could not be accounted for by its staff.
Drescher's death certificate cited chronic lung disease as the cause of death. But it also noted the use of Ativan, another name for lorazepam, among the "conditions" present at the time. Overdoses of lorazepam can lead to coma and, in rare instances, death, according to the U.S. Food and Drug Administration.
Bruce Drescher, Herbert's nephew, who has power of attorney over his legal matters, said he also hadn't known of the overdose until this week, saying, "that's a lot of medicine at once."
He added that he saw his uncle the day before the overdose, and "he was doing pretty good. ... I didn't think he'd go that quickly."
'You take their word'
Drescher said that if family members had been told of the overdose, they could have requested an autopsy. "When you have no idea about that, you take their word for it," he said.
Nursing home administrator Brenda Schrupp, however, challenged the Dreschers' account and said that she met with the family and told them about the medication errors. "We reviewed our investigation with them openly," Schrupp said. "I can't speak to what they understood."
Schrupp added that all employees involved in the medication errors were dismissed.
State requirements
Under state law, nursing homes must tell residents or their families when a medical error causes an injury or change of condition. But they are not obligated to say the error is the subject of a state investigation, said Janine McQuillan, an adviser at the Tubman ElderCare Rights Alliance.
"Families want to know how things are going for a loved one," she said. "Good care is a partnership between the family, resident and the home."
The home was cited for two federal rule violations and one state violation. A follow-up visit by investigators found that by Oct. 14 the home had completed promised changes in how it tracks medications and oversees administration of drugs, including a retraining of all nurses and medication aides.
Owatonna Care Center is a 55-bed facility owned by the for-profit Deseret Health Group of Utah. Deseret has two other facilities in Minnesota, in Faribault and Willmar, along with others in Utah, Kansas and Nebraska.
Paul Walsh • 612-673-4482