Resident Bleeds to Death at Care Facility That Has a History of Violations
By Clark Kauffman
The Arbor Court nursing home in Mount Pleasant, Iowa, is facing potential fines after a female resident bled to death. The facility has been cited by the Iowa Department of Inspections and Appeals for failing to respond to an internal, electronic warning related to two drugs administered to a resident last month. The facility's electronic system, which checks residents' health records, warned on Dec. 5 about a possible adverse drug interaction between the resident's blood thinning medication and an antibiotic she had been taking. According to the alert, the two drugs could potentially increase the risk of internal bleeding when combined. However, state inspectors say the patient's records indicate that the warning wasn't acknowledged by nursing staff, nor was the resident's primary care physician, who ordered the drugs, notified. The resident was admitted to a hospital emergency room with a gastrointestinal bleed on Dec. 12. She reportedly lost around four pints of blood, or about 45% of the blood in an average-sized woman's body, and was being given additional blood when she died. The state citation for failing to ensure each resident's drug regimen was free from unnecessary drugs marked the second time in eight weeks that the facility was cited for the same violation. A proposed $17,500 state fine is being held in suspension while the Centers for Medicare & Medicaid Services (CMS) considers whether to impose federal fines. CMS has given Arbor Court a one-star rating on a five-star scale for its health inspections, staffing levels, and overall quality. The facility has been cited for numerous, serious health and safety violations over the past 14 months, including a $166,551 federal fine in November 2021 for failing to property diagnose and treat residents' bed sores and a $27,000 suspended state fine after a resident fell from a mechanical device used to move her in and out of bed and died.
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