A female resident who was admitted on 8/15/12 was on Coumadin, a blood thinning medication requiring close monitoring to prevent severe bleeding episodes.
On 9/26/12, the resident was found unresponsive and was transferred to a hospital where she died the next day of brain hemorrhaging. A lab report showed the resident had blood clotting time six times the normal range.
The facility had failed to perform basic blood tests to ensure the resident's blood was not too thin. A number of nurses failed to properly monitor the resident's blood. The facility was cited for failing to ensure the resident was spared unnecessary drugs.
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