The Illinois Department Of Health has cited and fined Goldwater Care Gibson City when a resident died because the staff made two critical mistakes with their blood-thinning medication: they gave the wrong dose and failed to properly monitor how the medication was affecting the resident’s blood.
The resident in question had several health conditions, including heart problems that required them to take blood thinners. Initially, they were on a medication called Plavix, but they were eventually switched to a different blood thinner called Warfarin.
Three days prior to the fatal mistake blood tests showed dangerously high levels of the blood thinner in the resident’s system. The doctor specifically ordered the facility to:
– Stop giving Warfarin for three days
– Do blood tests on specific dates
– Then restart Warfarin at a lower dose (2.5mg instead of 3mg)
However, the facility ignored these orders. They continued giving the resident the higher 3mg dose for 24 more days and didn’t do the required blood tests. As the Director of Nursing later admitted, “the facility was not administering the Warfarin as ordered and not monitoring the resident’s labs as they should have done.”
The consequences were devastating. When the resident was finally tested, their blood was dangerously thin. They were rushed to the hospital with “lethal bleeding.” The hospital found severe internal bleeding, including:
– Bleeding into the space around their lungs
– Bleeding in their right lung
– A large blood collection in their hip area measuring about 3 inches by 2 inches by 3 inches
Sadly, the resident passed away shortly thereafter. The Medical Director was direct about the cause, saying “the resident clearly died from the hemothorax” (bleeding around the lungs).
What makes this particularly tragic is that these kinds of problems are preventable with proper monitoring. The medication’s guidelines clearly state that patients need frequent blood tests to ensure the medication isn’t making their blood too thin. Staff should also watch for warning signs of bleeding, such as unusual bruising or bloody stools.
The facility’s pharmacist revealed a complete breakdown in safety measures, admitting she “was unaware that the resident had out of target range or critical” blood test results. Another pharmacist emphasized that this level of oversight was unacceptable, stating that given the resident’s concerning test results, “closer laboratory monitoring should have been done. Failure to do so could result in increased bleeding and possibly 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. 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.
