CBS12 Investigates: Legal medication errors putting your loved ones at risk

CBS12 Investigates: Legal medication errors putting your loved ones at risk. (WPEC)

When you put a person in a nursing home, you expect them to get the proper care, but we found out not only are people not getting that care, the mistakes being made are perfectly legal.

CBS12 Investigates sifted through hundreds of nursing home inspection reports and found inspectors cited an alarming number of medication errors at nursing homes throughout the Palm Beaches and the Treasure Coast.


"I knew the system was broken,” said Paul Bergersen, “I didn't know how broken."

Bergersen has been married for 20 years.

The love of his life, Dr. Sandra Fernandez-Bergersen had a brain aneurysm that would take her from her classroom full of kids to a nursing home.

"It's the medical field, that is the stunner,” added Bergersen. “We are human beings and this is our health."

It is in that nursing home where Paul says her condition went from bad to worse, from what he calls overmedicating.

"When I pointed it out to the Feds, they did not think anything of it," Bergersen said.

It was a hard pill to swallow, because of a little known federal law nothing could be done.

Nursing homes are allowed to make medication errors rate up to five percent. It is within the accepted margin of error.

"It is costing the American taxpayer millions of billions of dollars for extra hospital stays, and the extra pain and suffering these patients are going through, if they live and pull out of it,” Bergersen explained. “It is just sad."


CBS12 Investigates looked through hundreds of inspection reports over the past three years.

Throughout our five county area, we found inspectors cited about a third of them for drug errors much higher than the allowed five percent. One was as high as 20 percent. That's four times the legal rate.

The reports we uncovered showed medication errors led to confusion, hospitalization and even death.

For those errors nursing homes doled out a few hundred thousand dollars - but that's not all. Not one was shut down and not one had their license suspended.


We shared our findings with Senator Bill Nelson.

He said slapping a facility with a fine doesn't come close to the kind of accountability he now wants to see happen as a result of our story.

"Nursing homes have to be responsible for dispensing medication," Sen. Nelson said.

With no specifics, CBS 12 Investigates contacted agency after agency at both the state and federal levels to share what we learned.

We demanded to know why more isn't being done to stop this troubling trend.

After all those calls, emails and phone conferences, we can report right now that change is in the works.

The Department of Health Office of the Inspector General or OIG refused an on-camera interview.

Officials told CBS12 by phone the OIG is ordering the Centers for Medicare and Medicaid Services or CMS to take corrective action to reduce harm to the most vulnerable in our society.

The OIG warns change will take time.

New provisions won't fully go into effect until November of 2019.


That's too late for Sandra and countless others who could easily end up just like her or already have.

"It needs to stop so other people don't have to deal with it," Bergersen said.

We contacted the nursing homes with the highest error rates.

All refused an on-camera interview.

To search nursing home inspection reports:

To file a complaint call (888) 419-3456 or visit

Statement from the Agency for Health Care Administration (AHCA):

“We are unable to provide an interview at this time.

In addition to the requirement that nursing homes shall not have medication errors of 5% or greater, each nursing home must provide pharmaceutical services to ensure accurate administration of medications. This includes the participation of a pharmacist consultant who helps develops and monitors processes within the facility to ensure resident do receive the correct medications.

During our nursing home inspections nurse inspectors observe the administration of medications to residents. Consideration is given to ensuring the correction medications / dosages are provided to the correct resident at the appropriate time, utilizing the correct route of administration. Additionally, the Agency investigates complaints regarding medication administration at a nursing home.

When a facility is cited related to medication errors, they are required to develop a detailed plan of correction, noting how they will remedy the citation within a given timeframe (30 days or less). One component of the correction process requires the facility develop additional quality assurance/ improvement practices to ensure these errors do not recur. Often, facilities involve their consultant pharmacist in developing these plans, which may include staff re-training, amended procedures and further staff supervision,” Shelisha Coleman, AHCA Press Secretary.

Statement from Centers for Medicare and Medicaid Services (CMS):

“The standards of practice are designed to fulfill Federal mandates to: decrease medication errors and adverse drug events; assure proper medication selection; monitor drug interactions, over-medication, and under-medication; and improve the documentation of medication administration. To that end, the following Congressional measure, The Omnibus Budget Reconciliation Act of 1987 (OBRA-87) generated new standards, or conditions of participation, for nursing facilities accepting Medicare and Medicaid funding in the area of quality of care, rights of residents, resident assessment, and quality of life. OBRA-87 and implementing regulations (42 Code of Federal Regulations) also addressed several issues related to pharmacy practice, including drug regimen review and the avoidance of medication errors. The following outlines the key provisions in OBRA-87 related to the practice of pharmacy and the provision of drug therapy in the nursing facility setting: Self-administration of medications. Residents may self-administer medications if an interdisciplinary team (e.g., attending physician, nurse, resident, and resident's family) has determined that the practice is safe. Unnecessary drugs. Resident's drug therapy must be free from unnecessary medications, those given in excessive doses, in excessive duration, or without adequate monitoring. Medication error rate. Nursing facilities must ensure that the medication error rate does not exceed five percent.”

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