What makes this report worth noting is that, unlike many of the violations noted on this blog, there seems to be no malevolence or cruel intentions present in the report. The apparent cause of the violations is human error, yet a resident almost died.
The details of the violations provide a glimpse into the workings of a nursing home where communication failed on several different levels and an elderly man narrowly avoided paying a terrible price.
The trouble began the way it often does with the elderly: a fall. After a week in the hospital and an operation to repair a Subdural hematoma (a collection of blood on the brain), the patient was transferred to Hearthstone.
Whenever a patient from a hospital enters a nursing home, the patient’s hospital records and physician orders are transferred to that nursing home and transcribed into a set of instructions for the staff.
A note was made on his medical charts not to administer Coumadin (an drug to prevent clotting) unless it was ordered by the surgeon who performed the operation. Anti clotting drugs are extremely hazardous to patients who have been treated for a hemorrhage. This should be common knowledge to trained medical personnel.
Here’s where things start to unravel. An nurse made an error transcribing his records. Coumadin and several other drugs were added to the official list of physician orders. The drugs were administered for the next five days.
If another employee had not called the patient’s doctor to inquire about an unrelated matter, the Coumadin would have continued to have been administered. Even after the nursing home learned of their error, they did not inform family members that it had occurred.
During that time, the patient’s health deteriorated rapidly. The patient’s chart noted the steady decline in ability. In one 24 hour period the patient transitioned from “able to feed self, follows directions with assist, is pleasant and cooperative” to “unable to state his name, unable to follow one step directions or eat his meals independently”
Still, it was not until the patient began voiding blood that an ambulance was finally called. Thankfully, he was treated for a gastro-intestinal bleed and survived.
Hearthstone Manor has 61 beds and, according to the Medicare Nursing Home guide, an excellent staffing model. So, how did everything fall apart?
People make mistakes. The nurse made a mistake when transcribing the initial patient care orders. But there were several opportunities to catch the error, and all were missed. The orders should have been verified by telephone. The patient’s rapid deterioration should have signaled a problem. Family members alerted to the error could have provided critical information concerning typical behaviors.
The story of this violation should serve as a warning to everyone with a friend or relative in a nursing home. Neglect can be as deadly as abuse in a nursing home. If someone you love has been the victim of nursing home abuse or neglect contact me for a free case evaluation.
Barry G. Doyle is a personal injury lawyer in Chicago and the founder of the Law Offices of Barry G. Doyle, an Illinois nursing home abuse and neglect law firm dedicated to representing nursing home residents and their families.. If you or a loved one has been killed, injured or suffered neglect in a nursing home in Woodstock, please order your free copy of A Family’s Guide to Nursing Home Lawsuits in Illinois. It’s full of helpful information that will help you protect your legal rights and is free to all Illinois residents.