NYS Health Inspectors: Resident’s Blood Clot Caused by Medication Error

After receiving a complaint in October 2013 against the Edna Tina Wilson Living Center, a 120-bed facility located in Rochester, the New York State Department of Health (DOH) fined the facility $4,450 for a medication error that caused a resident to develop a blood clot in her leg. The affected resident was admitted into the nursing home in September 2013. The resident’s medical chart indicated that she had received a heart valve replacement, had a pacemaker and was taking Heparin and Coumadin, both of which are blood-thinning medications. A physician ordered that a routine blood test be done on October 14, 2013 to ensure that the blood-thinning medication was working properly. Administration of the Coumadin was to be suspended temporarily under the lab test results came back. However, the blood test was never conducted, and for a period of nine days the resident never received Coumadin.

On October 21, 2013, the resident began complaining about pain in her lower left leg. After conducting an imaging test, a doctor determined that the patient had developed a blood clot in her lower left calf. The physician immediately ordered that the resident be placed back on Coumadin and receive Lovenox, a blood thinner that is injected in the affected area. Moreover, the physician ordered a blood test, which revealed that the patient was at risk of developing more blood clots. Staff members were also instruct to perform tests to ensure that clots did not form on the resident’s lungs.

Over the course of the investigation into the matter, DOH officials also discovered that lab tests for five other residents, including those on anticoagulants, were never conducted during the same time period. After working closely with staff members and administrators, DOH surveyors were able to trace the cause of the error to the implementation of a new computer system at the facility. Under the old paper system, nurses were required to manually fill out a lab request form and submit it to the secretary. Under the new computerized system, the nurses were not required to submit a paper lab request. The secretary stated that she was never trained or informed of this new change in policy and procedure. As a result, several lab requests were missed, resulting in actual harm to the resident.

In order to ensure that such an error doesn’t occur again in the future, administrators created a written policy pertaining to lab requests. They also provided training to all staff members about the facility’s new policy. The DOH report concluded that the appropriate changes were implemented in a timely fashion.

According to the “Nursing Home Compare” website, the facility received an overall rating that was below average.

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