Duluth nursing home cited after death from stroke

A Duluth nursing home has been cited for neglect in the case of a woman who died of a stroke last June after the home failed to give her a drug-thinning medication for 18 days.

Lakeshore Inc. was cited for neglect of health care because of the medication error, the Minnesota Health Department said in a report Tuesday.

The woman, whose name was not made public, stayed at the nursing home for nearly a month after she was hospitalized for an infection. She had some small strokes about 10 years earlier but they stopped after she began taking the anticoagulant drug Coumadin.

When she entered the nursing home on about April 29, she had a prescription for daily doses of Coumadin and an order for tests on May 7 to ensure that the dosage was correct. The home's policy was to discontinue the drug on the day of the blood test, give the doctor the test results, then get a new order for Coumadin.

However, the doctor's order was not transcribed correctly, so there was no blood test and the drug was not resumed.

The woman was discharged from the nursing home to her assisted living apartment on May 25 and hospitalized on May 27. The nursing home did not discover the medication error until a relative called on May 28. The woman died June 4 of a stroke caused by a clot.

The woman's doctor said she could not be certain that the medication error caused the death, but "there is ... a relationship, between not receiving the drug and suffering from a stroke," the report said.

By the time a state investigator arrived at the home on June 17, it had fixed the clerical problem, changed procedures and retrained staff. Still, the home was cited "because this obviously was a very serious problem," said Stella French, who supervises the investigators.

In statement Tuesday, administrator Paul Libbon wrote, "We deeply regret this incident and will continue to work closely with our staff and regulators to assure that appropriate procedures and policies are in place to provide for the safety of our residents."

Lakeshore includes independent-living and assisted-living apartments, as well as the short-term rehabilitation center where the woman was being treated. It is owned by Ecumen, a nonprofit chain based in Shoreview.

An online ranking of nursing home quality by Medicare gives Lakeshore a below-average rating of two of five stars, although its most recent inspection in November showed no rule infractions. The two previous inspections found 17 and 14 violations, compared with a state average of eight.

Warren Wolfe • 612-673-7253