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Discussion

Wow, really?

My 89 yr old father has dementia and recently went to live in a nursing home. The staff members there are kind and treat him well. But this happened: he had an appointment with his cardiologist and they noted that the MAR from the NH did not show him getting any Coumadin (he has a mechanical aortic valve). His INR was obviously subtherapeutic. I knew that he had at some point been getting the coumadin. I knew that they were drawing INRs weekly. I had asked them to fax the results to the cardiologist's office. The office never got those results. Presumably the physician for the nursing home *did*, but didn't act on the low value.

On investigation, this is what we learned. My mother died 2 weeks ago. During the 8 days surrounding her death, we had picked up my dad and taken him to their house to be with us. I asked the staff at the NH if there was a specific time we needed to have him back and was told no, they would just give him his med when he came back. Except. They didn't. The med assistant held the coumadin because she knew it was "time sensitive". So for about 8 days he got NO coumadin. On the 9th day, 2 days after my mother's funeral, he had a witnessed seizure. No hx of seizures. Wth? *I* don't hold meds without verifying with a physician, but she can?

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    During the six years I worked in LTC, I've bore witness to many medication fiascos. One former patient died secondary to supratherapeutic INR (she bled out of every orifice) and another former patient had a major CVA after the medication aides failed to administer Coumadin for several weeks straight.

    This is why families should stay on top of nursing home residents' medication regimens. Due to understaffing and a greater mix of unlicensed medication aides at some of these facilities, someone needs accountability.

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    This is poor education on the part of the NH to properly educate their MA's. And that MA's are doing the job that was once held by a nurse. MA's answer to nurses. And the nurse that is on duty at the NH needs to know what is happening with their residents and the medications.

    Who was drawing or sticking for the INR? Whomever receives that information is the one who needs to act on it. If he is being sent out to the lab for this, then the lab sends the results to the nursing home, the nurse needs to do something with that information. Such as call the MD for orders. Failure to act otherwise.

    I would call and ask to speak to the nurse. I wouldn't get into the whole "this one held this 9 days ago" stuff, as we can only go forward from here. What I would discuss is that you need to know that INR's are being acted on. And what the current order is for a therapeutic level to be achieved and maintained. Speak to the MD and be sure that she/he is on board with calling in orders to the NH. There needs to be a range, and there needs to be orders for how often INR's will get done.

    Now I do not know if this is true in most levels of care, most states, if it is a licensing issue, however, there should be an anti-couag policy and procedure.

    Good luck with this and wishing your father the best.

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