IDPH has cited and fined Elmwood Nursing & Rehab Center in Maryville after a resident there died of a brain bleed following a fall.
Anticoagulant medications, or blood thinners, are often important medications in the treatment of nursing home residents. They are used to combat the risk of stroke associated with atrial fibrillation (irregular beating of the heart) of pulmonary embolisms due to deep vein thrombosis. They need to be carefully monitored to be sure that the resident’s blood is neither “too thick” or “too thin” as either can lead to serious medical problems. They can also set up residents for serious medical complications such as a brain bleed after a nursing home fall even without direct trauma to the head. And that was the case here.
This resident was taking an anticoagulant to prevent a pulmonary embolism. She had what on the surface seemed to be a minor fall. She went to sit on her bed, bounced awkwardly, hit her head on the headboard, and then rolled out of bed. There was a small cut over the eye which the nurse on duty closed with steri-strips.
What is often crucial where there are bad outcomes from a nursing home fall is what happened after the fall. Standard procedure would be for the nurse to notify the doctor and to start a 72-hour fall watch. The purpose of notifying the doctor is to allow the doctor to make a determination as to whether the resident should be sent to the emergency room. The purpose of the 72 hour fall watch is to watch for signs of injury that were not immediately apparent at the time that the fall occurred. Sometimes this is a hip fracture, but one of the most important injuries which has a late onset of signs and symptoms is a brain bleed.
There were a couple of areas where this broke down in the care of this resident.
After the fall occurred, the nurse on duty called the nurse practitioner and notified her of the fall. However, when the nurse called the nurse practitioner, she did not tell the nurse practitioner that the resident was on a blood thinner. When a doctor (or as here, a nurse practitioner) gets a call from a nursing home after hours, they don’t have the resident chart in front of them and likely do not have the resident’s medical history committed to memory, so the nurse needs to bring the pertinent information to the attention of the doctor. In a fall, that would include the fact that the resident was on blood thinners.
When a 72 hour fall watch is being done properly, it starts with frequent checks in the immediate aftermath of the fall and then the frequency diminishes as time passes after the fall. The whole point of doing the checks is to catch any changes in condition as they first occur so that they can be reported to the doctor for immediate action.
Here, the fall was documented as occurring at 11:15 p.m. There are then follow-up notes times in at 1:15 a.m., 3:30 a.m., and 4:45 a.m., all of which were pretty unremarkable – and also very incomplete as they did not note and changes in the skin or bruising. They also did not note any projectile vomiting of brown vomit with “red chunks” which is something that the CNA assigned to the resident said occurred and was reported to the nurse. For her part, the nurse denies that the CNA made that report to her. Either way – the CNA failing to tell the nurse of the nurse failing to act on it – are both breakdowns in the delivery of care.
At 5:35 a.m., the nurse noted that the resident complained of being “hot” even though she was cold and clammy. Her oxygen saturation dropped to 52% (mid to high 90’s is normal) on room air and the nurse was unable to obtain a blood pressure. The nurse called 911 and the resident was brought to the hospital where a CT scan was done which showed that the resident suffered a brain bleed. She died on the way back to the emergency room from getting the scan done.
There are at least three breakdowns in the delivery of care after this resident’s fall. First, the nurse on duty failed to let the nurse practitioner know that the resident was taking a blood thinner after the resident had a fall. This is something that both the doctor and nurse practitioner were critical of, and the nurse practitioner said that knowing that would have led her to send the resident to the emergency room. This would have given the doctors there a window of four to six hours to stabilize and treat the brain bleed. Second, the post-fall checks were not frequent enough and obviously did nto capture the declines in the resident condition. Any decline should have resulted in a call to the doctor which in turn would have led to the resident being sent to the hospital that much earlier. Third, either the CNA was at fault for not telling the nurse or the nurse was at fault for not acting on it, but the episode of vomiting was a flashing red light that something was wrong, but it was never acted on and a crucial opportunity was lost. Each of these failure were contributing causes to this resident’s death.
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. 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.
Other blog posts of interest: