IDPH has cited and fined Pearl Pavilion nursing home in Freeport after a resident there died of a pulmonary embolism brought about by the failure of the nursing home to authorize the purchase of an expensive blood thinner medication that had been ordered for him.
A pulmonary embolism is a blood clot that becomes lodged in the arteries in the lungs. Usually these blood clots are formed in other parts of the body, typically in the legs, and then break off and travel to the lungs. Symptoms of a pulmonary embolism include shortness of breath and chest pain. The development of a pulmonary embolism is a medical emergency as they are often fatal without prompt medical intervention. Use of blood thinner or anticoagulant medications is the main means of prevention of the development of blood clots that can lead to a pulmonary embolism.
The resident at issue was admitted to the nursing home from the hospital. He had been admitted to the nursing home after being treated for a pulmonary embolism. He suffered from a condition known as activated protein C resistenace (a condition which can increase the risk of developing blood clots which lead to a pulmonary embolism), and a history of transient ischemic attacks (“mini strokes”), and ischemic stroke (the kind of stroke caused by a blood clot to the brain). In short, this was a resident who needed to be on blood thinner medications.
When the resident was transferred from the hospital to the nursing home, the doctor ordered that the resident receive an anticoagulant medication called apixaban twice a day. However, when the resident arrived at the facility, the medication was not on hand. The facility ordered the medication from the pharmacy but it was not delivered because it was expensive and required specific authorization from the nursing home. This was never given.
Because the nursing home never authorized the purchase of the medication the doctor ordered, the resident did not receive that medication or any other anticoagulant during the three days that he was at the nursing home.
The Director of Nursing told the state surveyor that they were not aware of the issue until a week after the resident died.
When a resident arrives at a nursing home with orders to get a medication that is not on hand, there are a number of options available to the nursing home. Completely failing to address the medical need that the medication is intended to address is not one of them. The most obvious option is to order the medication. The nursing home did so, but did not agree to pay for it, so they never actually obtained the medication. Another option would be to contact the doctor an obtain an order for an alternative medication. The nursing home never did that. Finally, there is the option of sending the resident back to the hospital because they cannot provide the resident with the treatment he needs.
Over the course of three days, there were two separate times each day where the resident was supposed to receive his blood thinner during medication pass, but the nurse handling the medications did not give it to him. There was nothing in the resident chart to suggest that these nurses raised the issue of the medication not being in stock with the administration of the nursing home. There was nothing to suggest that they contacted the resident’s doctor to let him know that a patient who was at risk for developing blood clots was not getting the blood thinner that was ordered or any blood thinner at all.
On the morning that the resident died, an aide went into see the resident around 6:15 a.m. At that time the resident was sweaty and clammy and complaining that he was having a hard time breathing. He asked to have his blood sugar checked and it was 103. The aide did what she was supposed to do, and reported this to the nurse. In response, the nurse did not go to see the resident, but told the aide to get a set of vital signs. The aide returned to the resident and took a set of vital signs. When she went back in, he was complaining that his legs were killing him (a sign of blood clots in the legs) and was obviously having a hard time breathing.
At about 7 a.m., the resident called his sister and asked her to call the nursing home because one of his legs was hurting badly. He was short of breath over the phone. She called the nursing home but could not get anyone on the phone.
At approximately 7:50 a.m., the resident activated a call light to summon the nurse. The nurse’s response was, “If he is well enough to turn his call light on, he can wait till I am done up here to see him.” When the aide and the nurse returned to the room at 8:00 a.m., the resident continued to complain of leg pain, was having a hard time breathing and asked to be sent out to the hospital. His blood sugar was rechecked and was over 320 even though the resident had refused breakfast.
After leaving the room, the aide asked the nurse whether the resident was going to be sent to the hospital. In response, the nurse resulted in said, “I’m figuring that part out.” The Director of Nursing told the state surveyor that around 7:30 a.m., she was told that the resident said that he didn’t feel good, was nauseated, and refused breakfast. She claims to have told the nurse to make calls to the doctor and the resident’s family but these calls were never made.
At approximately 9:28 a.m., the aide was sent to the resident’s room to check his oxygen saturation level. She found the resident lying in bed, pale and with no pulse. She called for help and began to perform CPR. 911 was called at the paramedics arrived. They attempted to revive the resident and brought him to the hospital where further efforts at resuscitation proved fruitless, and the resident was declared deceased.
The resident’s physician told the state surveyor that he never received a phone call from the nursing home about the resident. Had he been called and told of the resident’s symptoms, he would have suspected a blood clot and told them to call 911 right away. He further stated that the nursing home had the ability to send the resident directly to the emergency room.
There are at least three levels of failures that resulted in this nursing home medication error causing the wrongful death of this resident:
- The nursing home never obtained the blood thinner medication that was ordered for the resident. Obviously nursing homes are businesses and need to control their costs, so having a price threshold on medications is not an unreasonable thing to have in place. However, failing to either authorize the purchase or otherwise address the issue is completely unacceptable.
- Over the course of three days, there were multiple medication passes that occurred without the resident receiving the blood thinner medication that ordered for him. None of the nurses passing the medications those days brought this to anyone’s attention so that the issue could be addressed. Failing to give medications which are ordered and doing nothing further is substandard nursing care.
- On the morning that the resident died, he was demonstrating a clear change in condition with the complaints of pain and shortness of breath. Doctors are not in-house at nursing homes on a 24/7 basis, so nurses must serve as their eyes and ears and report to the doctors when a resident has a change in condition. We know what the result would have been had the nursing staff reported the changes in this resident’s condition to his doctor – he would have recognized it as the medical emergency it was and instructed them to call 911. This resident should have been in the emergency room 2-3 hours earlier which would have likely made all the difference.
Many of the nursing home cases we handle show this kind of pattern – multiple missed opportunities all along the way which would have avoided a catastrophic outcome. Here, there were opportunities from the moment this resident came in the door up until the last hour or so of his life to avoid this outcome. Missed opportunities yielding a tragic and avoidable outcome.
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. This is one situation where this is sadly true. Order our FREE report, Built to Fail, to learn more about why. 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.
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