January 3, 2016, the patient was put on com-
fort measures. She died on January 13, 2016.
The cause of death was attributed to bilateral
subdural hematomas, due to/as a consequence
of anticoagulation therapy with a contributing
factor of pneumonia.
The Geriatric and Long-Term Care Review
Committee was concerned that the resident’s
INR levels were not reassessed when she be-
“While there is no documented interaction
between nitrofurantoin and warfarin, altera-
tions in gut flora from antibiotics can alter
INR. Low dietary intake, and the combination
of a recent respiratory infection and an active
urinary tract infection, could also contribute to
increased INR levels,” stated the committee in
The LTCH had an electronic medical record
system with a standardized admission order
set including diet, vital sign protocols, bowel
management protocols, immunization proto-
cols and automatic renewal orders indicating
"all routine drug orders to be refilled weekly."
There were no automatic orders for INR
monitoring or monitoring of other drugs
where adjustment may be necessary to achieve
therapeutic/non-toxic levels (e.g., digoxin).
The Committee recommended that:
• All LTCHs should revise their standardized admission
order sets to include automatic monitoring of INR on
a prescribed basis and reassessment with medication
changes, changes in dietary intake or health status.
Further modifications could include monitoring of medi-
cations requiring dosage adjustments for toxicity or
• LTC documentation tools should allow staff to identify
trends in pain, behaviour or medical care that might
imply a significant change in health status.
• LTCHs are reminded of the importance of all staff
quickly recognizing and reacting to acute changes in
health status of their residents. Clear and established
channels of communication must be in place to allow
for prompt reassessment of LTCH residents who appear
to have had an acute change in health status.
• Physicians and nurses working in LTCHs are reminded
that a significant change in health status, whether acute
or subacute, in a frail elder, requires a thorough assess-
ment to determine the cause and potential treatment. At
a minimum, a history, physical examination and drug re-
view are required, a differential diagnosis developed and
investigations as appropriate for the goals of care should
be undertaken. Clear communication with the LTCH
resident and/or their substitute decision-maker must oc-
cur throughout this process. Thorough documentation of
assessments, goals of care and treatment is required as
a standard of practice for all health professionals.
• Any significant change in health status (e.g., decreased
mobility) should necessitate a complete and thorough
reassessment including appropriate testing and exami-
nations (e.g., X-rays).
ISSUE 2, 2019 DIALOGUE