Medication dispensing error nearly cost a woman her life. I-Team discovers it's not rare

WASHINGTON (7News) — When 74-year-old Rosezena Jackson was discharged from a hospital and went to a rehab facility to recover from a blood clot, she thought the worst was behind her.

Little did she know that within weeks, she would be in an intensive care unit, with a life-threatening condition caused by a mistake at Capitol City Rehab and Healthcare Center in Southeast D.C.

The facility gave Rosezena someone else’s pills and sent her home with the wrong medication.

"They gave her someone else's medication," said daughter Marquet Craig.

Marquet said it was not until her mom complained about swelling in her throat that the family examined what the facility had given her.

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Stuck down in the middle of her mother’s packs of medication were drugs with someone else’s name on them.

“She didn’t know it was somebody else’s,” said Marquet. “It was in the middle of all her medicine, so she believed that that was her medicine as well.”

The eldest daughter, Mildred, then discovered something even more troubling: The medicine her mom was taking, which belonged to someone else, was the blood pressure drug Lisinopril, to which her mother is severely allergic.

Mildred raced her mother to the nearest emergency room. When they arrived, she said Rosezena’s throat had nearly swollen shut. To survive, doctors put Rosezena on a ventilator and into a medically induced coma for more than a week.

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Medication errors are not rare. A 2022 report estimates that in the United States, seven to 9,000 people a year die from mistakes, and hundreds of thousands more suffer adverse reactions.

Experts said it is very likely those numbers are underreported.

“The extent of the medication errors that are reported to any agencies are probably much lower than the actual errors,” said Rita Jew, president of the Institute for Safe Medication Practices. “So, I think we're seeing the tip of the iceberg when we look at error reporting."

Jew said these mistakes are rarely an isolated incident with one person at fault, but rather what she calls it the "Swiss cheese effect" --- multiple holes that contribute to unreliable infrastructure within a facility.

“There are so many different systems that failed in order to lead to that medication error,” said Jew.

Marquet said when the family told the facility that Rosezena had to be put into a medically induced coma after being given someone else's medication, Capitol City Rehab and Healthcare sent her a letter apologizing for the "inconvenience." She said she was then badgered to give the medication back.

“He said, ‘Can I go with you to go get it? I'll go to you. I'll drive behind you and go in the house. You go in the house and get in and bring it to me,” said Marquet. “I said 'no, I’ll bring it back to you.'"

Marquet said she was not surprised by how badly the facility wanted the drugs, with another resident’s name on them, back.

“They want the evidence to go away that they gave the wrong medicine to her,” said Marquet.

The 7News I-Team pulled Centers for Medicare and Medicaid Services (CMS) records on Capitol City Rehab, formerly Transitions Healthcare, and found that this is not the first time the facility made medication errors.

According to inspection reports from 2020 and 2021, twice, the facility's pharmacist failed to identify a medication error. On several occasions, staff failed to administer medications prescribed by doctors, including not giving physician-ordered drugs to a patient for 19 days.

And despite a CMS five-star, “quality measures rating” displayed above the facility’s front door, the federal agency gave Capitol City Rehab a two-star “overall rating,” and a one-star rating, which is the lowest possible, on its health inspection. It also flagged and fined the facility for abuse.

When Marquet went looking for answers she said she got blamed.

“One of the nurses said, 'Oh, your mom should have read her medicine. That's her job to read her medicine. Y'all didn't read it?’ exact words,” said Marquet.

Not acceptable, according to D.C. Long Term Care Ombudsman Mark Miller.

“That’s totally inappropriate,” said Miller.

He said errors like these are inexcusable.

“The obligation is on the facility to make sure that you are getting the right medication as prescribed for you,” said Miller. “You give me someone else’s medication, that could kill them.”

Miller said the incident raises concerns beyond Rosezena Jackson.

“This lady fortunately is safe now. But what about the rest of the residents that are there,” said Miller. “You know, she obviously got someone else's medication. That resident, whose medication did they get?”

The 7News I-Team made multiple attempts to talk with Capitol City Rehab’s administrator, all of which went unanswered.

Marquet said she wants to make sure the facility answers someone.

“I think their license needs to be taken. I don't think they need to have anyone else in a nursing home anymore. I think they need to be shut down.”

Miller said his office will look into Rosezena Jackson’s case and forward what they find to the Health Department, which has the power to open a broad investigation.

For guidance or questions about long-term care facilities, the D.C. Long-Term Care Ombudsman Help Line is 202-434-2190. For legal help, contact the Legal Counsel for the Elderly’s hotline at 202-434-2120.