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Article:
"San Diego Nursing Home Receives Most Severe Citation"


Original source:
http://cbs2.com/topstories/local_story_074115601.html

CBS

Mar 15, 2006 6:53 am US/Pacific

(CBS) SAN DIEGO, Calif. A La Jolla nursing home that failed to follow a doctor’s instructions to properly care for a 79-year-old woman, leading to her death, has been cited and fined $94,000, state health officials said Wednesday.

The La Jolla Nursing and Rehabilitation Center was given an "AA" citation, the most severe citation the state issues, by the California Department of Health Services, state public health officer Dr. Mark Horton said.

The nursing home didn't properly monitor the woman through lab tests, as ordered by a physician and mandated by the facility's policy, when administering the woman's medication, state health officials said.

The unidentified patient was readmitted to the La Jolla facility Dec. 23 after she was treated for shortness of breath, a cough and a fever at a hospital. When the woman returned to the nursing home, her physician ordered that she be given 10 milligrams of Coumadin everyday, according to state health officials.

Because the adverse effects of Coumadin, which prevents blot clots, can include hemorrhaging from any organ or tissue, the patient was to be blood-tested daily to monitor her response to the drug, state health officials said.

The woman was taken to a hospital on Jan. 17 because she was vomiting and sweating. She was treated for massive bleeding on the brain and excessive anti-coagulation levels, but she died the next day, state health officials said.

Although the woman took the drug for 23 days, no records of lab tests exist, state health officials said.

One licensed vocational nurse interviewed by the state said she did not check any lab tests before giving the patient the drug. Another nurse said she did check lab tests, but that the results weren't current because they were from the patient's hospital stay, according to state health officials.


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