The two nursing home patients needed IVs of a saline solution mixture.
But the Sunderland nursing home had run out of automatic pumps to deliver the medication. And the nursing supervisor presiding over the patients' care that night at New England Health Center had scant experience administering intravenous medication, a state review found.
So the nurse guessed at the right amount, grabbing a flashlight to peer into the IV and make sure the dosage was correct.
Only later would a nurse on the next shift discover that the patients were being given the wrong medication.
The two patients, both in hospice care, were dead within two weeks. The nursing home said there was no connection between the medication mix-up and their deaths, and state health officials did not challenge that view.
State regulators cited the nursing home for several failures that evening last April, including "significant medication errors," and lacking services that "meet professional standards of quality."
The nighttime drug error, recounted in detail in new state investigative documents, provides a window into the inner workings of a nursing home ranked by state and federal regulators as among the worst in Massachusetts. It also shines a light on state oversight of long-term care facilities, as advocates for the elderly lobby for more scrutiny.
"The nursing supervisor said that she had not received any IV training from the facility," the Department of Public Health report states. "The nursing supervisor said she had not used the IV dial flow regulators in years and said that on [the April night shift] there was no IV pump available to accurately monitor the fluid volume in the facility."
Synergy's owners declined an interview but issued a statement that said the company has submitted a plan to the state health department to correct the problems discovered by investigators at its Sunderland nursing home.
Synergy never reported the episode to the state. Massachusetts regulations do not require nursing homes to notify the health department about medication errors or other accidents unless they "seriously impact the health and safety of the residents," said Department of Public Health spokesman Scott Zoback.
Regulations allow nursing homes to determine when an accident or error rises to the level that would require the state to be notified.
In the Sunderland nursing home incident, one of the residents, with congestive heart failure, received double the amount of sodium and 10 ounces more saline solution than prescribed. The other resident, with kidney disease, received the wrong solution. She was supposed to receive saline with dextrose, a sugar, but was given a straight saline solution.
The state's report noted that elderly patients with heart and kidney problems "are at greater risk for circulatory overload related to the delivery of excessive amounts of IV fluid."
State health department investigators, acting on a complaint, visited the Sunderland nursing home Aug. 6, scoured records from the April incident, and interviewed several staff members. Investigators found no mention of the medication errors in nursing notes from the night of the incident, and instead relied on interviews with staff and an internal report Synergy later wrote about the errors.
A nurse who discovered the errors after the medications had been dripping into the patients for four hours told state investigators she brought the mix-up to the attention of the nursing supervisor who committed the errors. None of the nurses or patients is identified in the report.
The nursing supervisor told the nurse she would call the residents' physician about the error, but there was no record that any call was made, according to the state's review of the nursing home's documents.
The nurse who discovered the error also told state investigators she thought some of her notes from that night might have been "rewritten." The state's report did not elaborate, and representatives of the state's health agency did not respond to requests for more information about the nurse's assertion.
Synergy's internal investigation "failed to detect the problem with [nurse] competency related to IV fluid administration," the state's report concluded. It noted that the nursing home's director of nursing, and a unit manager, acknowledged they did not know how to calculate whether a patient was receiving the correct amount of intravenous medication, at the prescribed rate, and the nursing home did not have a conversion chart that could provide guidance.
Synergy submitted a plan to regulators Sept. 11 detailing how it intended to correct the problems. It said all of the nurses at the Sunderland nursing home have since received one full-day training on intravenous medications, and the company said it will ensure a backup intravenous pump will be available at all times.
The plan also said the nursing home's executive director and director of nursing services have since been trained in "investigating high-risk events."
Not mentioned in the state's report is how the medication errors affected the two patients, an omission that mystified Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, a research and advocacy organization in Washington. Edelman said such reports following medication errors typically include information about whether patients were harmed.
Edelman, whose research includes state investigations of nursing homes, reviewed the Massachusetts documents at the Globe's request.
"This was multiple nurses, making multiple mistakes, over a long period of time," Edelman said. "There seems to be a lot of things that went wrong, and [Synergy's] investigation was pretty inadequate."
In the Massachusetts case, regulators concluded there were "significant medication errors" involved in the two patients' cases, but deemed the incident as not serious enough to warrant a financial penalty. Edelman has found that when most states find a problem in a nursing home, they decide it's at a level that does not warrant financial penalties.
Synergy said in a statement that its physicians and nurses examined the cases and concluded the deaths "had nothing to do with our facility."
There is no indication in the state's investigation of New England Health Center whether family members of the two patients involved in the medication errors were notified about the mistakes.
Kay Lazar can be reached at Kay.Lazar@globe.com