Resident Dies After Missing Six Doses Of Medication At Forest City Rehab & Nursing

The Illinois Department Of Health has cited and fined Forest City Rehab & Nursing Center when the facility failed to ensure a resident received a critical medication for several days after admission, which ultimately resulted in a stroke and the resident’s death.

The resident in question had a history of strokes caused by blood clots and was prescribed a blood-thinning medication called Xarelto to be taken twice daily to prevent future strokes.

Due to a combination of insurance authorization delays and facility communication failures, the medication wasn’t delivered until four days after admission. During this gap, the resident missed six doses of this crucial medication.

The situation became critical when family members noticed concerning symptoms. As documented in the progress notes, “Resident’s niece states ‘I’m scared my uncle might have had a stroke earlier when we were talking to him, but I really don’t know.'” Although staff checked the resident at that time and found no obvious signs of stroke, the next day the resident “started having a seizure in the dining room that lasted 2 minutes” and was rushed to the hospital, where they were diagnosed with another stroke.

The Nurse Practitioner explained the severity of the situation, stating that “missing 6 doses of the Xarelto could have contributed to having an acute embolic stroke.” She also noted that she “didn’t order an alternative blood thinner because she was under the understanding that the insurance issue was addressed promptly.”

The investigation revealed several systemic problems at the facility:
– A complicated medication storage system that staff couldn’t easily access
– Many nurses didn’t have access to the automated medication dispensing system
– Poor communication about medication availability
– Inadequate follow-up on delayed medications

The Director of Nursing demonstrated these problems while trying to locate Xarelto in their storage system, stating “Look at this. There isn’t even a label on this to tell me what is inside. I just have to look at each separate medication. This system is ridiculous. I hate it.”

Tragically, the resident remained hospitalized until they passed away several days later. The death certificate listed the cause of death as “recurrent embolic strokes.”

The Pharmacy Consultant confirmed that “Xarelto was not a medication stocked in the automated medication dispensing system” and that residents could be “at an increased risk of stroke if multiple doses were missed.” Only after this incident did the facility decide to start stocking this critical medication in their automated system.

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. 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.