Valley Healthcare Center
1680 North Waterman Avenue, San Bernardino, CA 92404
Citation Number: 240006862
Citation Date: 02/11/2010
Violation Date: 8/31/08
On 8/31/08, a 54 year old resident died from a toxic medication overdose due to a fatal medication error by the facility. Her physician had ordered Methotrexate, a medication used to treat rheumatoid arthritis, to be given 3 doses per week, 12 hours apart, beginning on 8/16/08. Instead of giving her 3 doses per week as ordered, Valley Healthcare Center gave her 2 doses per day through 8/28/08. The resident received 28 tablets during that time, more than 4 times the prescribed dose (6 tablets). A black box warning has been issued for Methotrexate because it can cause "severe, sometimes fatal, bone marrow suppression." The resident, whose vital signs were stable before the overdose, was hospitalized on 8/30/08 in septic shock and died the next day. Prior to her death, the hospital reported she was comatose and bleeding from all orifices due to probable Methotrexate toxicity with profound bone marrow depression. The facility's failure to follow the physician's medication order caused the resident's death.