On February of 2010, my father at the age of 89, was admitted to the local hospital for an evaluation because he started showing signs of slight confusion. At his admission, he was in a fairly good state of health. He did not have any serious life threatening illness. However, he suddenly died at the hospital on the fifth day of his admission while receiving combinations of anticoagulant medication (Aggrenox, IV Heparin, and Oral Warfarin). He had a sudden brain hemorrhage within 15-20 hours after receiving an increased dosage of 7.5 mg Warfarin and passed away less than 12 hours after the hemorrhagic stroke. His initial dosage of Warfarin was 5 mg.
The summary of his hospital stay was as follows:
Following his admission, tests showed he had a urinary tract infection. The doctor stated that the infection was the cause of my father’s confusion. A CT scan and an MRI of my father’s brain was also performed. It showed a minor blood clot on the left frontal lobe that had occurred six months earlier which was found on the left frontal brain. My father had never learned of the clot since he had no physical or neurological signs or symptoms from that clot incident during the six month period.
The neurologist recommended starting the patient on “Aggrenox.” After doing so, the neurologist never seemed to care for or follow up on my father after prescribing Aggrenox – she just let the osteopathic physician to care for my elderly father’s stroke.
On the second day of his admission, it was discovered by the osteopathic physician that my father had an atrial fibrillation. With the new diagnosis, this osteopathic physician immediately started my father on a regimen of anticoagulant treatment which included both IV Heparin and oral Warfarin.
A federal agency reviewed the case with its own medical doctor and found “the timing of starting Heparin and Walfarin in the setting of acute stroke has been a subject of controversy. The consensus is generally to wait for some time (typically two weeks) after an acute stroke because of the increased risk of bleeding, except in special circumstances. Those special circumstances were not clearly identified in your father’s case. The time at which your father began treatment with Heparin and Warfarin represented a departure from the standard of care, and this has been addressed with the physician.”
My father had confusion at times but did not have any other neurological complications. These three combinations of anticoagulant medication was continued for three days and on the third day, the osteopathic physician increased the dosage of Warfarin to 7.5 mg without consulting a neurologist. The day when the dosage was increased, my father had complained about dizziness and continuous indigestion all day long. Within 14-20 hours after receiving the increased dosage, he suffered a sudden hemorrhagic stroke and passed away very soon on the same day. Coagulation lab test showed very high P.T.19.6 (reference Range 12.0-15.0) a few hours prior his brain hemorrhagic stroke. However, this was ignored by the nurses and the physician.
From the bottom of our hearts, our family knew he did not die from natural causes or coincidentally, from the sudden bleeding that occurred that time. It happened because he was an inpatient for several days under the improper care of the osteopathic physician who had no knowledge of the crucial waiting period, and the negligent neurologist and nurses. He was receiving anticoagulant medication continuously at the wrong time. We took him to the hospital to prevent this type of unfortunate and unexpected death. However, ultimately, his life was ended abruptly by an unqualified osteopathic physician, the neurologist’s malpractice, the nurses’ collective negligence, and the hospital’s general negligence.
The nurse and her charge nurse checked my father 11 hours prior his passing and noticed serious neurological status changes. She wrote on her Acute Care Record: “patient self-moaning; left arm, left leg not moving; his grips-unequal (R greater than L); left side facial droop”. She also wrote “patient awake, groaning in bed, pt. not answering questions at this time, pt. holding tele-monitor in right hand, not letting go, pt. not following commands at this time not squeezing hand equally. Will continue to monitor”.
These are descriptions of symptoms even non-professionals are able to identify as symptoms of a stroke. Yet, these were completely ignored and neglected by the registered nurse and her charge nurse for more than 1 hour and 15 minutes until my family came to see my father the next morning. We can assume he was holding tele-monitor with his right hand in an attempt to get help, he grabbed anything he could reach with his right hand since left side of his body was already paralyzed.
The nurse later claimed to the state department of health investigator that the patient did not seem to speak English, and therefore did not respond to her comment, so she decided to keep monitor, which makes absolutely no sense to us. My father was perfectly capable of speak English conversationally. If she truly believed that he was unable to respond due to language barrier, then why did she not immediately call for an interpreter given the urgent situation? Does law not require that the hospital provide an interpreter? (The state investigator failed to question the nurse about her failure to call the interpreter). My father could not respond to anyone at that time, not because he did not know how to speak English, but because he was already suffering from the serious stroke due to the bleeding in the brain.
A federal agency’s investigation subsequently revealed that the nurse actually paged the physician (D.O.) when she first noticed my father’s stroke at 7:00 am, but the physician never showed up. However she and her charge nurse never again attempted to call any physician who could have helped my father who was suffering from a serious for more than 1 hour and 15 minutes until my family came to visit the patient and noticed his condition (the left side of his face was drooped, he was paralyzed, and unable to speak) and requested immediately to notify the physician.
My father’s sudden bleeding in the new area of right front of brain occurred around 15-20 hours after receiving increased dosage of 7.5mg Warfarin. The timing of starting anticoagulant medication on this patient was proven to be at the wrong time and had caused the deadly bleeding in the brain. We also believe he was overdosed which ultimately caused his sudden, unexpected death. The osteopathic physician and neurologist’s decision to administer anticoagulant treatment on an 89 year old patient should have been made after sufficient consideration of the dangerous side effects of brain hemorrhaging – especially on elderly patients. The hospital should not have been allowed this unqualified physician (who had no knowledge of crucial waiting period) to care of any stroke patent. Further, these nurses’ obvious neglect towards a serious stroke suffering patients is outrageous, and simply unacceptable.
The hospital also failed to provide immediate and essential care to their sudden stroke suffering patient for a very long time, when he desperately needed it. The osteopathic physician finally arrived after 45 minutes from our family’s request (2 hours from first notification of stroke), and ordered a CT scan of my father, but the CT was done more than 2 hours later from his order. Why did the hospital staffs and the physician leave a paralyzed, urgent patient waiting for so long? Any logical person would know how to prioritize the urgent patient. His patient’s rights and the basic standard of care were seriously violated.
For the last 2 years since my father’s passing, I have been putting all of my efforts hoping to find the truth through the Department of Health in Washington state investigation. However, the hospital, medical, and nursing commissions repeatedly ignore the facts in the case and have closed the case with no cause of actions after 8-10 month long investigations.
They never seem to perform thorough investigations as they always claim to do so. It is already tragic to lose my father unexpectedly; however, every agency in the State Department of Health, in the name of protecting patient’s rights and better care, added insult to injury to my family already suffering the great loss of a loved one. It is an abuse of their power and the system, which is not right and is in serious need of improvement.
We decided to file complaints to federal agencies out of frustration and great disappointment with the state departments of health. The federal agencies all concluded after their own investigation that many of our allegations were substantiated. I filed complaints 4 weeks ago to the Secretary of WA State Department of Health in regards to its investigators failed and poorly executed investigations, as well as their supervisors and directors’ negligence. However, I am yet to receive any response.
We have deep concerns related to the quality and necessity of medical care that my father received during his less than 5 days of hospital stay. We strongly believe he was neglected by the hospital, physicians, and nursing staffs due to his age. This is obviously a case of elderly abuse. We believe he was not the only patient who received improper care and wrongfully lost lives. We believe similar incidents have been going on for a long time in this hospital; however the incidents are either go unknown, unnoticed, overlooked, and/or ignored.
Our family hopes that my father’s tragic story can help to inform other families so that they will not have to go through what we have been and are still going through.
Thank you for taking the time to read our story.
Kimberly Yang
If you have comments, please email them to us at WaPatientRights@gmail.com. Thank you.