Inspectors: Medication errors linked to woman’s acute kidney injury

The Iowa Department of Inspections, Appeals and Licensing took over responsibility for many of Iowa's licensing boards in July 2023. (Photo illustration via Getty Images; logo courtesy of the Iowa Department of Inspections, Appeals and Licensing)

A Council Bluffs nursing home is facing a potential fine for medication errors that may have resulted in serious injury to the resident.

State inspectors allege the staff at Prairie Gate, a 32-resident nursing home in Council Bluffs, recently committed a series of “significant” medication errors in its treatment of a female resident.

According to the inspectors, in early March the woman’s cardiologist ordered that she be given Bumetanide twice per day in 2-milligram doses for 3 days, followed by a once-daily dose of 2 milligrams.

The home didn’t initiate the once-per-day order, which meant the woman didn’t receive the drug from March 10 through March 15. A second error occurred when she was allegedly given, for two full months, a 2-milligram dose twice per day rather once per day. That error was compounded when the home began providing an additional, prescribed 1 milligrams per day.

The net result, according to state inspectors, was that the woman “received 5 milligrams of Bumetanide a day, for roughly 58 days, when 3 milligrams was ordered.”

A nurse at the woman’s cardiologist’s office allegedly told inspectors such an error could cause acute kidney injury, adding that she didn’t understand why the home did not question the order in March.

The state inspectors’ report does not indicate whether the resident survived, but it does state that she was discharged from the facility on May 28 with a diagnosis of acute kidney injury.

The state has proposed, but held in suspension, an $8,000 fine.

Earlier this year, the state fined Prairie Gate $6,250 for inadequate nursing services related to an alleged failure to address pressure sores. That fine was later reduced by the state to $4,062.

Prairie Gate has a one-star overall rating, as well as a one-star rating for both staffing and quality measures, on the federal Centers for Medicare and Medicaid Services’ Care Compare website , which scores the nation’s nursing homes on a five-star scale.

CMS also reports that it has imposed no fines or penalties against the facility in the past three years.

Prairie Gate is owned by a nonprofit organization, Presbyterian Homes & Services.

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