IDPH has cited and fined Bethany Rehabilitation and Health Care Center nursing home in DeKalb after a resident there suffered a brain bleed and seizures due to a medication error regarding the administration of his coumadin.
Many nursing home residents take anticoagulant or “blood thinner” medications. Used for a variety of purposes such as a history of blood clots, atrial fibrillation, stroke prevention, and management of other circulatory and cardiac conditions, this class of medication can be crucial for maintaining the health and well-being of the resident for whom the medication was ordered.
However, the use of this medication has to be carefully managed. If the blood is considered “too thick,” or subtherapeutic, it can lead to blood clots which can have catastrophic consequences; if the blood is “too thin,” or supratherapeutic, this can lead to uncontrolled bleeding.
To ensure that the resident remains in the desired or therapeutic range, the resident must receive regular blood testing called a PT/INR test which measures whether the blood is in the therapeutic range. If the blood is outside the therapeutic range, then the nurse must contact the doctor to notify him that the resident had an abnormal lab result. From there, it would be up to the doctor to make adjustments in the dosing of the blood thinner medication or to take other steps to treat the condition.
The resident at issue had a medical history which included atrial fibrillation, a stroke, and a pulmonary embolism – all conditions for which use of a blood thinner was warranted. The blood thinner which was used for him was coumadin and was being managed by a coumadin clinic.
The resident was seen at the coumadin clinic which gave orders that the resident should receive 5 mg of coumadin on Mondays and 2.5 mg of coumadin every other day with a PT/INR test to be done in weeks. When he was seen in the coumadin clinic, his INR level was 3.0, which was the high end of the normal range.
However, when the orders were entered into the record at the nursing home, it provided for the resident to receive 5 mg of coumadin on Monday and 7.5 mg of coumadin all other days. This means that the resident received three times the prescribed dose 6 days a week for a two-week period.
When the PT/INR test was scheduled to be performed at the end of the two weeks, the machine would not give a reading. A call was placed to the doctor and an order was received to redraw the blood the following morning. When the test was run again the following day, the lab called back stating again that the results were inconclusive. Plans were made to redraw the lab again the following morning.
The next morning, the resident started to show slurring of his speech which was getting progressively worse. The nursing staff paged the physician and nurse practitioner, but when they were not able to get a response, they called 911 and had the resident sent to the hospital. There labs were drawn which showed a prothrombin time (PT) of 181.5 (normal is 19.7 – 28.8) and an INR score of 21.54 (normal is 2.00 – 3.00). A CT scan of the head showed that the resident had a left-sided subdural hematoma. Following this, the resident demonstrated loss of cognitive function and suffered seizures.
Continuity of care is a critical issue in the long-term care setting. Residents are often seen by outside providers who issue orders for the ongoing care of the resident with the expectation that those orders will be carried out as specified. When that does not happen, disaster awaits. Here, the order were for the resident to receive 2.5 mg of coumadin every day other than Monday when he was supposed to receive 5 mg. The issue arose when the orders were not entered into the record correctly and the resident received 7.5 mg dose the other 6 days of the week. This led directly to the brain bleed sustained by the resident with catastrophic results for him.
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