IDPH has cited and fined Warren Barr Oak Lawn nursing home after a resident there died from a massive pulmonary embolism caused by the failure to give a blood thinner medication as ordered.
Maintaining continuity of care from a hospital to a nursing home is critical for the safety and well-being of a resident. When someone is admitted to a nursing home from the hospital, they are generally recovering from a significant injury, illness, or surgery and have significant near-term and long-term needs. Special care has to be taken to make sure that the care needs that the doctors and staff at the hospital have determined that the resident requires are being met during the initial stages of the resident’s admission.
When a resident is admitted to a nursing home from a hospital, the nursing home receives a list of medications that the resident is supposed to be receiving. That list is supposed to be verified with the providers at the hospital and then double-checked by a second nurse at the nursing home to ensure that all orders, including medications, are correctly entered into the resident’s chart. When this process does not happen, there is an increased risk that the resident will either not receive a necessary medication or be given a wrong medication or the incorrect dose of a medication that was ordered.
This kind of nursing home medication error can have catastrophic consequences, and that was the case here.
The resident at issue was admitted to the nursing home after having spinal surgery following a fall at home. When the resident was discharged from the hospital to the nursing home, there was an order in place for him to receive heparin, a blood thinner. Many patients will receive a blood thinner after a major surgery to prevent the developments of blood clots – a complication which is known to occur following major operations. This is especially true when the patient has significant mobility deficits, as was the case here.
However, when the resident was admitted to the nursing home, the order for heparin was not copied from the discharge papers onto the patient’s medical record. As a result, during the twelve days that the resident was in the nursing home, he did not receive a single dose of the blood thinner that was ordered.
On the twelfth day of his admission, the resident had episodes of vomiting and had a fixed stare. The nursing home staff had the resident sent to the hospital, where it was discovered that he had a massive pulmonary embolism, or a blood clot that became lodged in the lung. A pulmonary embolism can lead to cardiac arrest and death. Sadly, that was exactly what happened in this case, as the resident died later that day. Cause of death according to the death certificate was massive pulmonary embolism and cardiopulmonary arrest.
Well-run businesses run on systems, and a nursing home is a business. This nursing home actually had a system in place similar to the one described above. Unfortunately, it was not followed, leading to this very preventable medication error.
The obvious reason that this medication error occurred was the failure to follow the system that was in place. The deeper question is why the system wasn’t followed. Investigation by IDPH revealed that the nurse who made the mediation error was an agency nurse, or a temp. We tend to see a lot of agency nurses in facilities where they have hiring and retention problems, generally due to low pay and heavy work loads. Temporary staff can help address this, but there is little chance to ensure that they are trained in the systems and processes that must be followed for the consistent delivery of routine care.
In the end, this was a death that was a product of the nursing home business model, where understaffing of the nursing home and lack of investment in the staff are cardinal features – and this is because those kinds of expenses cut into the bottom line. 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:
Catastrophic brain injury results from medication error at Alden Town Manor
Diabetes medications not given at Alden Estates of Orland Park
Failure to give anticoagulant medication at H&J Vonderlieth Living Center
Click here to file a complaint about a nursing home with the Illinois Department of Public Health.