A disabled resident at a south Minneapolis assisted-living facility suffered a seizure and later died after going for 10 days without a key medication, according to a state investigation that cited the facility’s staff for failing to restock the prescription.
The March 6 death is being blamed on St. Paul-based Accessible Space Inc. for failing “to adequately supervise staff to ensure medications were available,” according to a summary of the Health Department report.
The medication, phenobarbital, had been keeping the resident’s seizures in check “for several years” before he missed his twice-a-day prescription 19 times over a 10-day period, the report noted. The client last took the drug on Feb. 23, the report said. On March 5, he “had a seizure that lasted for 15 minutes” and died the next day in a hospital, the report continued.
The death certificate said the seizure brought on respiratory failure.
The report did not identify the client, who was described as suffering from seizure disorder and multiple sclerosis and needing assistance with medication because of cognitive difficulties.
Kristy Schutt, director of program services for Accessible Space, said the findings will not be appealed, noting that some staff members have been disciplined and “all the remaining staff properly retrained.”
Some of the disciplined staff members had worked with the resident for 18 years, Schutt said. “The care provided to him over the years, the family was very happy with,” she said. “It was an unfortunate incident.”
The same client had also missed three days of phenobarbital in December and a drug for a urinary tract infection for all of January, investigators found.
The report also noted that another client had missed doses of medications for treating ulcers and hypertension late last year and early this year, also because the drugs were out of stock.
This marks the second time in nearly two years that Accessible Space has been found responsible for a serious medication error.
In 2012, a male resident was found “gray and pale and dazed” on the floor of his apartment after staffers set up his medications incorrectly. State investigators found that the man had not received two prescribed drugs, a pain reliever and an antihistamine, for three days. He was transferred to the hospital on the fourth day with “an altered mental status,” according to a June 2012 investigation report.
The Department of Health cited the operators for allowing an unlicensed staff person without adequate training to schedule medications for the resident.
The nonprofit Accessible Space operates residential facilities throughout the metro area, elsewhere in Minnesota and 25 additional states for seniors or other adults needing round-the-clock assistance.
Three licensing orders were levied against Accessible Space for the March incident. A follow-up in April found that Accessible Space had made the necessary corrections.
Staff writer Chris Serres contributed to this report.