New Hope Care Center
2586 Buthmann Road, Tracy, Ca 95376
Citation Number: 030006469
Citation Date: 8/20/2009
Violation Date: 8/24/2009
Class: AA
Penalty: $ 100,000

A 78-year-old resident died on 9/16/08, two days after being hospitalized in critical condition due to bleeding in her brain. New Hope Care Center had been administering Coumadin, a blood thinner, and two other medications affecting blood clotting without monitoring her blood as needed to detect bleeding complications. Her husband found her in extreme pain and very lethargic on 9/14/08, and urged a nurse to assess her. The nurse informed the husband she had paperwork to do. Despite family requests, the resident was not assessed until hours later when the family insisted that 911 be called. Her death certificate indicated that inappropriate bleeding or clotting, secondary to medication, was a significant condition contributing to her death. The facility was cited because it failed to appropriately monitor the resident's anticoagulation therapy, failed to assess symptoms indicating the resident may have been bleeding in her brain, failed to contact her physician immediately and failed to ensure an immediate transfer to the hospital for emergency treatment. These failures led to her death.