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Health Department reports Wadena nursing home gave wrong meds, leading to one death

Investigators from the Minnesota Department of Health concluded Fair Oaks Lodge of Wadena, Minn., neglected three residents by giving them the wrong medication or administered medication at the wrong time, leading to the death of one of them.

In a report released Friday, MDH ruled "the preponderance of the evidence indicates that neglect did occur when medications were given in error" to a resident, an incident that led to her death. The report also said other "significant medical errors" were made during that time.

The woman who died was admitted to Fair Oaks in April 2009 due to advancing Alzheimer's disease. Around 7 p.m. on June 1, 2009, the resident was given medication meant for another patient. The Fair Oaks employee recognized the error about 10 minutes later and contacted the hospital emergency department physician, who advised the facility staff to monitor the resident's neurological status and take her blood pressure in a half-hour. In that time, the woman's blood pressure dropped to 58/42, she was breathing with pursed lips, periods of 15-second apnea were noted and her pupils were fixed and non-responsive, according to the report. She was taken to the emergency room and admitted into the intensive care unit. She died on June 7, 2009.

On June 8, 2009, another woman was admitted to Fair Oaks for physical rehabilitation following a fall in her home. On June 12, she was also given medication meant for another patient, and was rushed to the emergency room at the hospital. That resident remained there until early the next morning, when she recovered and was discharged back to the home on June 13.

A third incident detailed in the report says a resident on May 27, 2009 was given his scheduled doses of medication too close together -- at 3:45 p.m. and 5:50 p.m. -- and became unresponsive for 2-3 minutes, with weak pulse and non-reactive pupils. That resident was taken to the hospital's emergency room for monitoring, and recovered with no further complications.

The names of the residents were not included in the report, referring to them only as "Resident #1," "Resident #2" and "Resident #3." Staff members were not identified, either.

Comment from Fair Oaks was not immediately available at the time of this report.