Nursing Home Resident Dies Following Coumadin Overdose

Case Overview

This case involves a 75-year-old female patient with a medical history of atrial fibrillation who was admitted to a skilled nursing facility for long-term care. In addition to her atrial fibrillation, the patient was also suffering from a number of other conditions when she was first admitted to the facility, including diabetes, Parkinson’s disease, and an upper respiratory infection that had persisted for some weeks. As a consequence of her atrial fibrillation, the patient had been on Coumadin for an extended period of time. During her stay at the nursing home, the patient’s INR was never tested, due to the fact that the patient’s nurse never properly carried out the treating physician’s orders to do so. As a result, the patient suffered a massive gastrointestinal hemorrhage, which eventually caused her to enter hypovolemic shock. The patient eventually died as a result of her bleeding.

Questions to the Nursing expert and their responses

Do you serve as an administrator at a skilled nursing facility like the one described in this case?

I have been in various nursing administration positions from Head Nurse through Director of Nursing both in skilled nursing facilities and acute care hospitals.

Have you ever had a patient develop this outcome?

I have had many patients on Coumadin. Monitoring and titrating this drug is very important in order to ensure that the correct dose is given each day.

Can you opine on the importance of accurate nursing notes?

Nursing notes are to be reflective of the patient situation. All changes, progress, lack of progress and status quo must be documented. The notes are a vital communication to the team that cares for the patient. During all of this time, patient safety and positive outcomes for the patient and family have been my main concern and focus. I have taught this concept to hundreds of nurses and still teach it today.

About the expert

This highly qualified nurse has been practicing for over 40 years. She has a BS in Nursing from Lehman College and an MA, Med and EdD in Nursing Administration from Columbia University. She has authored publications in the Journal of Nursing Administration, Nursing Clinics of North America, Clinical Nurse Specialist, and the Quality Review Bulletin. Previously, she was an Associate Director of Nursing at Bellevue Hospital Center. She now serves as an adjunct lecturer at a New York City medical college and a Staff Development Coordinator at a medical center in the Bronx.