Vision Quest Property Management Neglect After Medication Error
In a report dated December 29, 2106, the Minnesota Department of Health alleged Vision Quest Property Management in White Bear Lake Failed to Follow Physician’s Medication Orders for 11 Days – Resident Suffered a Stroke
Vision Quest Property Management Neglect After Stroke and Hospitalization After Medication Mistake
Based on the report Vision Quest Property Management, had determination that neglect occurred. The client did not receive a prescribed anticoagulant medication for 14 days because the medication was not reordered by the licensed during staff, alleged perpetrator (AP), and staff members failed to report that it had not been administered. Within a week after the issue was discovered, the client had a stroke requiring hospitalization. The client died as a result of this stroke.
The client received services from the home care provider, including medication management. The client was on a long term oral anticoagulant therapy due to a higher risk of stroke, secondary to atrial fibrillation and a history of prior stroke.
Ten days prior to the client’s death, routine testing was conducted of the client’s blood clotting rate to ensure the client’s medication was at a safe and effective dose. Upon review of the clotting time results, AP noted it was abnormally low. The AP reviewed the medication administration record that indicated one milligram (mg) of warfarin was to be given daily on Tuesday, Thursday, Saturday, and Sunday, and 0.5 mg on Monday, Wednesday, and Friday. The AP discovered the client had not received an anticoagulation medication for the preceding 14 days. Pharmacy documentation confirmed the client’s medications were not on schedule delivery, and needed to be reordered every 14 days. The medication had not been reordered by the AP during the time period prior to the 14 days of missed doses. The AP notified the client’s physician and was directed to restart the medication at the previous dose and to redraw the blood work in one week. Due to the client’s fragile condition, the physician did not order any additional interventions.
Four days later, the client had symptoms of stroke, emergency medical services were called, and the client was admitted to the hospital. The client was diagnosed with a stroke and treated with intravenous blood thinners. The client subsequently passed away, and the death certificate indicated the immediate cause of death was an embolic vascular accident.
The family was interviewed and stated they had not been informed of the missed anticoagulation days of oral anticoagulation medication, until hospital staff notified them.
The primary care physician was interviewed and indicated in his/her medical opinion, the client missing 14 days of oral anticoagulant therapy was a direct cause of the client’s death.
The AP stated during an interview that the nurse who usually reordered the medications was off duty for an extended period of time. The AP was refilling the client’s medications, and missed reordering the anticoagulation medication. The AP indicated that if the medication was listed on the client’s medication administration record but was not in supply, the personnel who were assigned to administer medications should have reported the medication was not administered as prescribed. Several staff members had assisted the client with medications, but none had reported the medication being unavailable.
Vision Quest Property Management – Report Suspected Neglect and Abuse
For more information from the Minnesota Department of Health, Office of Health Facility Complaints concerning nursing homes, assisted living and other elder care providers view resolved complaints at the MDH website.
If you have concerns about financial exploitation or any other form of elder abuse or neglect contact Minnesota Elder Abuse Attorney Kenneth LaBore toll free at 612-743-9048 or toll free at 1-888-452-6589 or by email at KLaBore@MNnursinghomeneglect.com.