Tuesday, November 25, 2008

Warren Barr Pavilion Fined for Poor Supervision and Failure to Give Prescribed Medications

66 W. Oak St. in Chicago.
FINED- 2003
Warren Barr Pavilion was fined $5,000 for an incident
in which a resident sustained a bruised and cut arm
after leaving the facility unsupervised. Police found
the resident wandering in the street and took her to a
nearby hospital. Although the resident had made
several attempts to leave the facility, an elopement
risk assessment was not performed prior to the
incident. Staff determined the resident left the
facility through a rear exit door, which was near her
room. When the door is opened, an alarm is supposed to
signal the front desk. However, there was a problem
with the door and the alarm did not sound when the
resident left.
FINED- September 16, 2004
Warren Barr Pavilion was fined $10,000 for failure to
ensure that residents receive medications as
prescribed, to train temporary nursing staff on the
administration of medications and to address
complaints regarding ongoing medication errors.
As part of an annual inspection and complaint
investigation, Department surveyors learned a resident
was hospitalized after mistakenly given his roommate's
According to interviews, an agency nurse gave the
resident his medication as well as his roommate's
pills to control blood pressure and heart rate and an
The resident said the agency nurse also had tried to
administer insulin, but he told her that he did not
take insulin. The resident experienced acute medical
changes and was admitted to the hospital for low blood
pressure and a low heart rate.
Another employee said the agency nurse did not ask
the resident his name or check his identification band
prior to giving the medication. Surveyors found there
was no consistent method used by nursing staff to
check patient identities prior to giving medications
and temporary nurses, who were not familiar with
residents, were often used to distribute medications.
A grievance log listed five complaints in a one-month
period involving medications not given, medications
not given in a timely manner or medication errors.
Although these incidents were investigated by the
facility, there was no evidence a comprehensive plan
was established to prevent medication errors in the

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