Bakersfield Healthcare Center
Citation Number: 120004404
Citation Date: 7/2/2008
Violation Date: 10/1/2006
Class: AA
Penalty: $ 100000.0

The facility was cited for failing to reassess a female resident for adverse consequences when using Coumadin (a blood thinner) in conjunction with Mobic (a medication used to treat joint pain). The interactions of these two medications were known, as indicated by the recommendation of a consulting pharmacist on 10/5/06, to increase PT/INR, a test used to determine clotting factor and to monitor the effects of Coumadin. The pharmacist recommended to use Tylenol instead of Mobic; this recommendation was not acted upon. The resident was transferred to an acute care hospital on 10/19/06, where she passed away on 10/20/06 from the interaction of the two medications. The facility was also cited for failing to reassess the resident for appropriate alternatives when she refused blood draws and for failing to develop a careplan regarding these concerns.