“Get thee to a nunn’ry” ~Shakespeare

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Several years ago I helped a friend move her daughter into a college about two hours away. During the drive back I get a call from my ex. She asks what I am doing.

I’m driving back from moving Kim into school, why?

Can you pull over?


I need to talk to you, please pull over. Really.

This was after David was at the new place just a couple of weeks. He was in one of their regular residences, but they quickly moved him into their medical residence because he was having some seizure issues. We thought maybe he had a virus or something. This center has a licensed medical facility AND a specialty hospital, as well as the school and everything else. The medical residence is nice, the rooms are dorm-ish, but the hall reeks of “hospital.” Multiple nurses 24/7 on the floor and nurse assistants.

So, my ex tells me what is going on. A week later we want to document it and make sure everyone who should know knows what happened. Hence, I present to you that email. Remember, David is fine, and he is still there.

After a number of mistakes were made regarding our son’s care during a two week stay, we have been told that there have been/will be investigations into these matters in order to ensure they do not happen again. We believe, however, that the goal should also be to remedy whatever systemic weaknesses you are suffering from that would permit these kinds of serious errors to happen in the first place, so that it becomes a safer environment. Dr. M gave David excellent and attentive care, but without competent nursing support, this care became severely compromised.

To recap:

We were told that an unsupervised nurse trainee cancelled David’s principal seizure medicine abruptly through a transcription error. This placed David at great medical risk, especially considering that he was in your facility at that point because of hard to control seizures. His 7 missed doses of Keppra were not discovered or noticed by any of the staff for two and half days. This error was discovered by David’s mother.

Even after this occurred, one of David’s seizure medications was not signed off by the nurse responsible for administering the medicine. This was discovered by David’s mother. Failure to sign off on medications is tantamount to the medication not being given, since there is no documentation—an infraction of state law as well as dangerous. We were told a directive was being sent to nurses to remind them—but we were also told that the failure to sign off is a “universal problem” by one of the nurses.

David received an emergency medication (Diastat) that is under partial recall. The Diastat was not checked to see if it was defective. This was discovered by David’s father. No one at your facility seemed to know about the recall, which put other children at risk as well.

At one point, David’s feeding was not properly administered, as discovered by a staff member from the residence. Air was being pumped into his stomach rather than formula. This happened even after David’s mother and some of the nurses had taught numerous LNAs and LPNs how to use this pump.

We have been told by SK that investigations have taken place. But unless specific recommendations coming from them are implemented, these investigations are a waste of time. What specific changes are being instituted to ensure that these errors are not repeated?

When we discuss the situation with David with employees at the facility, we have often been told that they are not surprised and that they have seen numerous mistakes similar to those with David. Overall there appears to be a low opinion of the care given at the medical residence. On the other hand, there do not appear to be similar issues with the nursing given by the health center, which has been excellent and consistent.

We have met another parent whose child was also subject to a serious medical error while at the medical residence, some time ago. We have heard that when a serious medical error occurs, a committee is convened to investigate. Has that happened in the case of David’s missed Keppra doses?

It is hard to believe that an institution with a stellar reputation like that of yours would have so many problems in its children’s “specialty hospital.” In our opinion this hospital does not at this moment consistently provide a safe medical environment for its patients, because of errors such as these, large and small. It seems to us crucial that some serious changes occur at your facility to raise everyone’s confidence, not just ours.

Yes, they investigated. Yes, we met with the top people, they showed up state mandated documents on error counts, internal documents, etc. Was anything done? Not much. That’s what happens when certain people get certain jobs not based on qualifications for said job. Lots of beds in that residence, you know?


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