When Medication Mismanagement Turns Deadly in Illinois Nursing Homes

State investigators recently determined that medication mismanagement on the part of the Goldwater Care nursing home in Gibson City directly led to a resident’s death. The resident died after receiving the wrong dosage of a powerful blood thinner for nearly a month.

Nursing homes are trusted to care for some of the most vulnerable members of our communities. That trust is built on the expectation that residents receive safe, competent care – including when it comes to medication. However, that trust is all too often broken by carelessness, poor communication, or outright neglect.

Medication errors are some of the most dangerous forms of nursing home abuse and neglect. These mistakes can lead to serious harm, and in some cases, death. If you or a loved one suffered harm due to a medication error at a Chicago nursing home, contact our team at DePaolo & Zadeikis Attorneys at Law. 312-263-7560.

How Common Are Medication Errors in Nursing Homes?

Errors involving medications happen more often than many people realize. In long-term care facilities, studies have found approximately 27% of residents may experience some kind of medication-related issue. Some of these mistakes are relatively minor. Others, like the situation involving the man at Goldwater Care of Gibson City, can be life-threatening or deadly.

Common causes of medication errors include:

• Giving the wrong drug to the wrong patient
• Administering the incorrect dosage
• Failing to administer medications on time
• Not monitoring for side effects or adverse reactions
• Failing to follow physician orders

Such errors aren’t just accidents, and should be prevented. 

In the case of the resident who died due to a medication mistake at Goldwater Care, staff administered the medication for 24-days. They continued dosing the man at the original amount, despite a physician’s direct order to pause the medication, run lab tests, and resume it at a reduced dosage.

Types of Medication Errors That Can Be Life-Threatening

Not all medication mistakes carry the same level of risk. However, in a nursing home, even a small oversight can have serious consequences. Older adults often have underlying health conditions, take multiple medications, and may be unable to advocate for themselves when something feels wrong. This combination makes them especially vulnerable.

Certain types of medication errors can quickly escalate into medical emergencies. Some lead to long-term disability. Others can be fatal. Some of the worst nursing homes in Illinois have been cited for making these types of serious mistakes, which include:

Overdoses and Incorrect Dosing

Too much of a medication can cause organ failure, internal bleeding, or other life-threatening complications. Blood thinners, insulin, and pain medications are particularly dangerous when misused.

The resident at Goldwater Care died due to Warfarin toxicity. The overdosing caused him to suffer severe internal bleeding. The man was hospitalized in critical condition, and died less than a week later.

Drug Interactions

Many nursing home residents take multiple medications. Staff must be vigilant about how those drugs interact. When they fail to do so, residents can suffer seizures, kidney damage, cardiac events, or worse.

Missed Doses or Delayed Medication

Missing a critical dose, especially for conditions like diabetes, epilepsy, or high blood pressure, can lead to sudden and serious health emergencies.

Ignoring Allergies and Pre-Existing Conditions

If staff administer drugs that are contraindicated based on a resident’s known allergies or conditions, the results can be catastrophic.

Why Do Medication Mistakes Happen in Nursing Homes?

Nursing home residents depend on staff to manage their medications accurately and safely. However, when systems break down, those residents are often the ones who pay the price. Medication errors in long-term care facilities don’t happen in a vacuum. They’re often the result of systemic problems that could have been prevented.

Medication-related mistakes in nursing homes are rarely the fault of a single person. In most cases, they point to broader issues inside the facility. Some of the most common reasons these dangerous errors happen in nursing homes include:

Under-Staffing

Chronic staffing shortages are one of the biggest threats to resident safety. When there aren’t enough qualified nurses or aides, corners may get cut, and residents may suffer.

Lack of Training

Medication management in elderly populations is complex. Staff must understand how to follow orders precisely and recognize side effects. Inadequate training may lead to serious gap in care, putting residents at risk.

Poor Communication

Communication breakdowns between doctors, nurses, pharmacists, and aides can lead to errors. Medication changes may not be recorded properly, or instructions may be misread.

Weak Oversight

Some facilities lack basic checks and balances. No one reviews medication orders, no one verifies dosages, and no one tracks side effects. Such lack of accountability can turn small mistakes into fatal outcomes.

Signs Your Loved One May Have Suffered from a Medication Error

In many nursing home facilities, families aren’t immediately told when a mistake has been made. Staff may not notice the problem, or they may attempt to downplay what happened to avoid liability. Therefore, it’s important for families to stay alert to changes in their loved one’s health, mood, and overall condition.

Medication errors don’t always show up in obvious ways. The symptoms may look like natural progression of age or illness. However, if the timing lines up with a new prescription, a dosage change, or a sudden decline, it may be worth asking questions.

Some common red flags families should watch out for include:

• Sudden changes in health without explanation
• Confusion or altered mental state
• Unexplained hospitalizations
• Bruising, bleeding, or frequent falls
• Seizures or loss of consciousness
• New or worsening symptoms after a prescription change

Even if families are unsure, they shouldn’t hesitate to ask for copies of their loved ones’ medical records and breakdowns of their medication schedules. Asking questions may prevent further harm, as well as uncover important details the nursing home hasn’t shared. 

Legal Rights of Nursing Home Residents in Illinois

Illinois law provides several protections for nursing home residents. Under the Illinois Nursing Home Care Act, residents have the right to:

• Receive adequate and appropriate medical care
• Be free from abuse and neglect
• Have their care plans followed
• Be informed about their condition and treatment

Goldwater Care of Gibson City, the facility where the recently deceased man lived, was assessed three violations by the Illinois Department of Public Health for violating residents’ rights. One of the fines was levied due to the man’s death, while the other two resulted from incidents involving other residents.

If a facility violates these rights and a resident is harmed, nursing homes may face consequences, in addition to fines. The resident or their family can file a nursing home abuse lawsuit. In cases involving death, a wrongful death claim may be appropriate.

Who Can Be Held Responsible for a Medication Error?

When a nursing home resident is harmed by a medication error, families are often left with more questions than answers. Who made the mistake? Who should have caught it? When can a nursing home be liable for abuse committed by its staff? And, who is legally responsible for the harm it caused?

Accountability in these cases isn’t always straightforward. Medication errors often involve multiple parties – from the staff who administered the drugs to the doctors who prescribed them and the facility leaders responsible for oversight. Identifying the right source of liability is a critical step in pursuing a legal claim.

Some of the parties who may be held legally responsible when a medication error occurs in a nursing home include:

Nursing Home Staff

Nurses and aides who administer medication are expected to follow medical orders and monitor residents closely. 

Facility Administrators

If the facility is under-staffed, undertrained, or lacks proper safety systems, administrators may be liable.

Pharmacists

In some cases, the wrong medication is delivered, or the medication is dispensed incorrectly.

Doctors

If a physician fails to properly prescribe or monitor medication, it may be considered medical malpractice.

A nursing home abuse lawyer may help investigate and determine who is responsible, as well as identify what legal action may be appropriate.

What Can a Lawsuit Accomplish?

Pursuing legal action after a medication error isn’t just about getting compensation—it’s about demanding accountability. When a nursing home violates the trust families place in it, and that violation results in harm or death, the legal system provides a way to respond. A lawsuit can uncover what went wrong, put pressure on facilities to change unsafe practices, and provide financial support for the losses a family has suffered.If you’re facing this situation in Chicago or anywhere in Illinois, know that you’re not alone. An experienced nursing home abuse lawyer can help you understand your options, protect your rights, and move forward with a case that holds the right people accountable. To learn more about your options, contact our nursing home abuse lawyers at DePaolo & Zadeikis Attorneys at Law. Call 312-263-7560 for a free initial consultation.