Nursing Home Patient Dies After Nurse's Transcription Error, Mistakenly Discontinued Medication

State investigators say a woman recovering from spine surgery died of a massive stroke in June after a nursing home failed to give her a medication prescribed to prevent blood clots.

The doctor's order was incorrectly transcribed by a nurse at at the nursing home, and the home did not have adequate checks to spot the error, its administrator acknowledged Monday. The home was cited for neglect.

However, the medication error probably did not cause the woman's death, her physician told a Health Department investigator. The patient was at risk of blood clots because of immobility and was prescribed Lovenox. A different drug would have been ordered to prevent a stroke, the doctor said.

The administrator of the 60-bed home said the nurse who made the transcription error was fired, the staff was retrained and procedures were changed to double-check medication records.

The report, made public last week by the department's Office of Health Facility Complaints, said this is what happened:

The unidentified patient was moved from a hospital to the nursing home on June 2 for rehabilitation therapy with orders for the daily Lovenox injection.

She was given the drug for three days, mistakenly did not get it on the weekend, then got it again for four days.

Then the treatment was stopped because a nurse mistakenly had written that it was to end on June 11, instead of July 11 as ordered.

The patient had a massive stroke on June 17 and was sent to the hospital, but returned to the nursing home two days later for end-of-life care. She died on June 24. For more, read the story.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.

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