The Illinois Department of Public Health issued a citation and fined Alpine Fireside Health Center in Rockford after a resident had a fall from a wheelchair and experienced a brain bleed.
This case is a classic example of a situation where things had been going wrong for weeks and everyone missed it.
The resident had a medical history which included atrial fibrilation. This is a condition where the heart at time beats in an irregular fashion and can produce blood clots. Blood clots can in turn cause a host of problems, most notably strokes. The usual treatment for this issue is drug therapy, most commonly a blood thinner like coumadin, and this is what the doctor ordered.
The use of coumadin is not risk free. When the blood is too “thin” this can lead to bleeding and when it is too “thick” this can cause clots. Find the “sweet spot” or the therapeutic range is done through a blood test called a PT/INR level test. Regular PT/INR testing is required to make sure that the resident stays in the therapeutic range. If the level goes too high (is supratherapeutic) or too low (subtherapeutic), then the dosage can be adjusted to bring it back into the therapeutic range.
Here the nursing home failed to get the required lab work done to measure whether PT/INR levels were in the therapeutic range. This apparently happened because the nursing staff failed to complete the lab requisition form. Without that lab work being done, the doctor did not know whether to adjust the coumadin and she continued to get the same dosage on a daily basis.
Things went on without incident until the resident had a fall while transferring herself from her wheelchair to her bed. There is no immediate indication that she struck her head and when she was assessed by the nursing staff she had elevated blood pressure and pain in her knees.
The ordinary course of action in most nursing home would be to do a 72-hour fall watch after an incident like this to make sure that there were no additional injuries which were not immediately apparent. This would include neurological checks to make sure that there was no head injury.
When the resident’s daughter arrived at the nursing home later that day, she recognized immediately that her mother was not herself and took her to the hospital herself. When she got there, lab work indicated that her PT/INR level was 7.4 (normal range 2.0-3.0) which was a critically high level. A CT scan of the head showed that there was a subdural hematoma, a form of brain bleed. The hospital discharge summary attributed this to the high coumadin levels.
This is a case where there were a number of issues:
- The required lab work was not done as ordered which hid the fact that the PT/INR levels were climbing out of the normal range. This denied the doctor the ability to make adjustments to the coumadin dosage to bring it back into the normal range.
- The circumstances surrounding the nursing home fall are not entirely clear, but a wheelchair-bound resident likely required assistance with transfer and this probably should have been included in her care plan. This is especially true because falls can have serious consequences for patients who use anticoagulant or blood thinning medications such as coumadin.
- Once the fall happened, the follow-up was not done correctly. In most well-run nursing homes, there is a process for a 72-hour fall watch which would have detected the onset of neurolgic problems. Instead it was left to the resident’s daughter to discover them and act on them. That is not how things should be done.
We believe that many falls at nursing homes have their roots farther back in time than the day the resident hit the floor, and had the staff acted in the right way any time before that, the fall could have been avoided. Contact our law firm to have our experienced nursing home lawyers to review your situation. There is no charge for the call and your are not obligated to hire our firm if you do call.
Other blog posts on nursing home falls: