IDPH has cited and fined the H & J Vonderlieth Living Center in Mount Pulaski after a resident there suffered a stroke due to the failure of the nursing staff to administer an anticoagulant (blood thinner) medication ordered by the resident’s doctor.
Atrial fibrillation is an irregular heart beat where the upper chambers of the heart contract in a way that is out of rhythm with the lower chambers of the heart. It is a condition which can have serious complications, including strokes and heart attacks. When you have an irregular heart beat, blood can pool in the upper chambers of the heart and form blood clots. Either whole clots or broken-off portions of clots can travel from the heart to the brain, where it can impede circulation to the brain, resulting in what is known as an embolic stroke.
To combat the risk of stroke, doctors often prescribe anticoagulant medications, or blood thinners, which are intended to prevent the formation of the clots which cause the strokes. However, for the medications to be effective, they must be given as ordered so the resident’s blood remains within the therapeutic range. Too “thin”, and the resident will be at risk of excessive bleeding; too “thick”, and there is an outsize risk of blood clots forming.
The resident at issue was admitted to the nursing home after apparently being treated for an infection. The transfer orders included orders to give antibiotics as well as 150 mg of Pradaxa (an anticoagulant medication) every 12 hours. When the transfer orders arrived, the Acting Director of Nursing transcribed the orders onto the resident Medication Administration Record. However, she failed to include the anticoagulant medication on the list of medications to be given and as a result, the resident never received the medication.
Five days after arriving at the nursing home, the resident was found to have left sided weakness and was nonverbal. The resident was sent to the emergency room where she was diagnosed as having suffered an embolic stroke (a stroke caused by a blood clot to the brain) due to missing the ten doses of her anticoagulant medication.
Additionally, the investigation by the state showed that orders for two antibiotics were not copied as ordered in the transfer orders from the hospital, and as a result, the resident did not receive those medications as ordered. Further, there were two additional medications that did not make it onto the Medication Administration Record at all, and as a result, were never given : an order for Tylenol for pain and an order for a cough medication.
The sum total: medication errors with 5 separate medications, one resulting in catastrophic injuries for this resident.
Nursing homes are businesses, and well-run businesses have systems in place to make sure that the routine operations of the business get accomplished seamlessly. The receiving and transcribing of orders for newly-admitted or readmitted residents to the nursing home is one of those routine operations. This nursing home did not have a system in place at all at the time to make sure that orders received were entered into the chart properly, and as a result, the care that this resident received was rife with errors, one of which resulted in unnecessary injury to this resident.
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.
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