DC Health opens investigation after 7News uncovered medication errors at nursing home
WASHINGTON (7News) — The D.C. Department of Health has launched an investigation into a District rehabilitation and nursing home facility in the wake of a 7News investigation that exposed a near-deadly medication error.
In December of 2022, Rosezena Jackson’s family checked her into the Capitol City Rehab nursing home to recover from a recent hospitalization for a blood clot. They said they trusted the facility to take care of their mother, which included giving her prescribed medications.
"They gave her someone else’s medicine," said Marquet Craig, Rosezena Jackson's daughter.
The family showed the 7News I-Team the medications given to Rosezena, including a package of Lisinopril, a blood pressure drug to which Rosezena is severely allergic. It had someone else’s name on it.
Doctors had to put the 74-year-old into a medically induced coma for more than a week to help her survive.
When 7News first reported this story, the family showed us a letter from the Director of Capitol City Rehab, apologizing for the "inconvenience" that nearly killed Rosezena.
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7News did some checking and found federal inspection reports that showed this was not the first time the facility had made medication mistakes.
According to inspection reports from the Centers for Medicare and Medicaid Services in 2020 and 2021, twice, the facility's pharmacist failed to identify a medication error. On several occasions, staff failed to administer medication prescribed by doctors. In one case, nursing staff failed to give a patient a physician-ordered drug for 19 days.
We took Rosezena's case to D.C.'s Long-Term Care Ombudsman, Mark Miller.
“You give me somebody else's medicine, that could kill me,” said Miller. “If they had followed their protocol, you know, what medication, am I giving it to the right resident in the right room, you know, it's not rocket science."
Miller did some checking and according to him, it turns out that more than a month after the error occurred, Capitol City Rehab still had not reported the mistake to the D.C. Department of Health. The mistake happened in mid-December.
“It should have been reported immediately,” said Miller.
D.C. law requires that for facilities like Capitol City Rehab, incidents that result in harm be reported within eight hours.
And according to Miller, the facility’s administrator told a member of the Ombudsman's staff that he had “no knowledge of the circumstances that led to Rosezena Jackson being hospitalized.”
A shocking revelation to her daughter, Marquet Craig, who said he'd known about the grave situation from the time her mother was hospitalized.
“He absolutely lied,” said Craig. “He knows exactly what's going on. I told him she was in a coma, I told him everything that was going on with my mother myself and I showed them a picture of my mom, saying, ‘this is how my mom looked’.”
The photo Craig said she showed him was one of her mother intubated and in the ICU.
“[I showed him] the one with her laying in that bed with the tube down her throat. I showed it to him,” said Craig. “He don't care about nothing. He don't care nothing about nothing but his paycheck.”
7News spoke with a representative for Capitol City Rehab who told us they cannot talk about the case. They did follow up with an email that said while ownership was not aware of the incident, they are now and want staff “to live up to the high standards they’ve set.”
Prior to the mistake at Capitol City Rehab, the family said Rosezena was vibrant and independent. Now, she has to have full-time care and is learning how to walk again, feed and care for herself.
D.C.'s Health Regulation and Licensing Administration said their investigation is ongoing and they cannot speak to us about it until it's closed.
7News will report the findings as soon as they are available.
Statement from Capitol City Rehab:
"Due to privacy laws, the facility is not permitted to discuss the specifics of any resident’s care. But whenever Capitol City finds an opportunity for improvement it actually engages a Quality Assurance Performance Improvement Committee (inter-disciplinary committee) to fully assess all policies and procedures, trainings opportunities, and to develop a root cause analysis of the issue at hand. While ownership was not aware of the situation at the time, it is now aware and has asked leadership to live up to the high standards they have set."
