Medication error rates of 52-89% on several medications is neglect.
Failure to apply splint correctly 85% of the time is neglect.
Neglect occurs when a person, either through his/her action or inaction, deprives a vulnerable adult of the care necessary to maintain the vulnerable adult’s physical or mental health. Examples include not providing basic items such as food, water, clothing, a safe place to live, medicine, or health care.
Signs of neglect. (from Washington State Department of Social and Health Services)
The above examples of error rates are just a few that have occurred to my son while living at a state operated intermediate care facility for those with intellectual and developmental disabilities (ICF/IDD). These issues and others have been reported to the administration and there have been several investigations done and the conclusions returned have been “allegations unfounded.” I find these conclusions indefensible given the documents that have been submitted for review.
One such issue that went on for several weeks started when my son developed swelling and pain in his right ankle – the ankle that had very recently recovered from a serious sprain. The lack of response from the medical and nursing team from the very beginning of this injury being reported to the day I removed the splint was met with frustration. It was a very simple and straightforward issue that could have had a very simple and straightforward response – it turned into something totally different.
It was not until I was totally frustrated that I even mentioned the word “NEGLECT” and that is when the superintendent “self-reported” to Residential Care Services (RCS) and the first investigation was done. That investigation took several months to complete and the allegations were deemed unfounded. During those months I was not allowed to talk with anyone at the facility regarding the care since it “was under investigation.”
This is a link to the email exchanges that I had with the Health Care Coordinator (HCC – RN), the Nurse Manager (RN4), the Habilitation Plan Administrator (HPA) and the ICF/IDD Superintendent.
Since that time, I have requested to have the issues investigated again and have provided more documentation to RCS. I have felt as if I have been the one being investigated because each conversation that I have had with an investigator has started with what they have heard about me – trying to find issues with what I have reported or how I have acted.
The only thing that they have been able to say is that the photos that I have provided are not “proof” because I could have photo-shopped them. Their “proof” is the documents and charting of their nurses and staff (which now have been found to be in error when trying to reconcile medications dispensed to medications documented as administered). They have not and will not consider email correspondence or medical charts from outside medical providers. They have not enlisted healthcare professionals to review the allegations of medical and nursing neglect until this very last investigation involving almost countless medication errors. Yet, I am the one who is looked at for wrong doing.
In doing the research for these allegations I have learned that the Department of Health and therefore the Nursing Care Quality Assurance Commission has no ability to investigate since they are not the licensing agency for the healthcare provided at the ICF/IDD. Since the issues are systemic to the nursing care at the ICF/IDD it is up to the licensing agency to investigate. Here is a link to the letter I received from the Nursing Care Quality Assurance Commission – Discipline Section, Health Services Consultant.
So, it’s back to the drawing board of contacting DSHS and asking for explanations of why the allegations are unfounded.
All residents are at risk of harm until these and other issues are acknowledged and corrected.