Blood Test Failure Nearly Kills Resident on Blood Thinner at Sunrise Skilled Nursing & Rehab

The Illinois Department of Health has cited and fined Sunrise Skilled Nursing & Rehab when staff failed to perform required weekly blood tests for a resident taking the blood thinner Warfarin, causing his blood to become dangerously thin and resulting in life-threatening internal bleeding. The resident’s INR level reached greater than 10 when it should have been between 1-2, requiring emergency hospitalization, blood transfusions, and medication to reverse the dangerous effects of the blood thinner.

The resident in question had been prescribed Warfarin, a powerful blood-thinning medication, to prevent blood clots related to his history of pulmonary embolism and deep vein thrombosis. This medication requires careful monitoring through weekly blood tests called PT/INR to ensure the blood is not too thin, which can cause dangerous bleeding, or too thick, which can cause deadly clots. The resident’s physician had specifically ordered these tests to be performed “weekly on Mondays” and the facility’s own care plan identified him as being at “high Risk For Abnormal Bruising or Bleeding Related to Anticoagulant Therapy with Warfarin.”

Despite these clear requirements, the facility completely failed to follow through with the monitoring. The resident’s last blood test had been completed in late March, but no additional tests were performed even though his physician had issued a specific order for weekly monitoring in late April. The Director of Nursing later admitted that the resident “should have been drawn weekly” and acknowledged that a test “should have been drawn” in early May “and wasn’t.”

The consequences of this failure were nearly fatal. When the resident was rushed to the emergency room, hospital staff discovered his blood had become dangerously thin with an “INR level of greater than 10” when the normal range should be “0.9-1.1 with a suggested therapeutic range of 2-3” for someone on blood thinners. His hemoglobin level had dropped to a critically low 3.8 when the normal range is 14-18, indicating severe blood loss from internal bleeding.

The resident’s sister expressed her outrage at the facility’s negligence, stating she was “concerned about the resident’s Coumadin not being checked at the facility like it is supposed to be, it is to be checked weekly and hasn’t been checked since March.” She emphasized that “when the resident was in the ER his blood count was 3 and his INR which is supposed to be between 1-2 was greater than 10. This is not acceptable and whoever is to be checking to make sure his INR is being checked failed.”

The resident required immediate life-saving interventions including emergency medications to reverse the blood thinner’s effects and multiple blood transfusions. Hospital records show he “received four blood transfusions” on one day and “one” additional transfusion several days later. He was admitted to the intensive care unit as a “critically ill patient” with multiple serious conditions including “Sepsis, Leukocytosis, GI Bleed, Elevated Lactic Acid Level, Elevated INR.”

The resident’s physician confirmed the severity of the situation, explaining that “an INR of 10 is not ideal because it allows bleeding and could lead to a person bleeding to death.” The doctor had to completely re-evaluate the resident’s medication regimen due to the facility’s failure to monitor his condition properly.

During the hospitalization, doctors discovered that the resident had developed a large cancerous mass in his intestines, which may have been related to or complicated by the internal bleeding caused by the unmonitored blood thinner. The resident required major surgery to remove the “invasive moderately differentiated adenocarcinoma” that had developed in his colon.

The facility’s explanation for the monitoring failure was inadequate and revealed systemic problems with their laboratory procedures. The Director of Nursing claimed she “called the lab and was told that it wasn’t drawn because there was no carbon copy with the lab requisition, but that it still should have been drawn,” suggesting that administrative paperwork issues were being used to justify life-threatening medical negligence.

This incident highlighted dangerous gaps in the facility’s medication monitoring systems despite having written policies requiring proper surveillance. The facility’s Anticoagulant Policy clearly states that staff should “monitor the PT/INR very closely while the individual is receiving Warfarin, to ensure that the PT/INR stabilizes within a therapeutic range” and requires “periodically checking hemoglobin/hematocrit, platelets, PT/INR, and stool for occult blood.” The policy also mandates using “a Warfarin flow sheet or comparable means to follow trends in anticoagulant dosage and response,” none of which were properly implemented in this case.

The facility was forced to implement extensive corrective measures including staff re-education, new tracking systems, mandatory audits, and restrictions on agency nursing staff until they received proper training on blood thinner monitoring protocols. However, these changes came too late for the resident, who had already suffered life-threatening complications that could have been easily prevented with proper weekly blood test monitoring as originally ordered by his physician.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.