With some verdicts totaling up to $44 million, cases related to blood thinners can produce some of the worst liability outcomes for senior living providers.

An 85-page report, published by Marsh, reveals falls are the most prevalent cause of liability costs for senior living providers, with brain injury cases having some of the worst outcomes including death or severe, permanent injury.  Blood thinners can exacerbate injuries from a fall and can also cause or contribute to spontaneous brain hemorrhages. Recent verdicts and settlements involving anticoagulation therapies highlight the need for greater awareness of the risks associated with blood thinners, with some verdicts totaling $44.1 million, $41 million, $30 million, $5 million, $4.1 million, $2.4 million, and $2.35 million.

Insights on the inherent risks associated with such injuries were presented in a featured panel discussion at DRI’s 2024 Senior Living and Long-Term Care Litigation Seminar.  Beth Wilson, President of Excelas, LLC, moderated The Bloody Truth about Brain Bleeds & Blood Thinners: Suits, Surgery, and Solutions, with attorney James Bream of Cray Huber Horstman Heil & VanAusdal, LLC, and Dr. Sean P. Polster, MD, of the Neurovascular Surgery Program, Department of Neurological Surgery, University of Chicago Medicine and Biological Sciences.

The Importance of Evaluating Various Brain Hemorrhage Types, Etiologies, and Combinations of Factors

Four broad types of intracranial hemorrhage (ICH), epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and intraparenchymal hemorrhage, were thoroughly discussed by panelist Sean Polster, MD, who co-authored a publication on the topic, along with Magid-Bernstein, J., Girard, R., Srinath, A., Romanos, S., Awad, I. A., & Sansing, L. H., Cerebral Hemorrhage: Pathophysiology, Treatment, and Future Directions, Circulation research, 130(8), 1204–1229, Epub Apr 14, 2022.

ICH can be the result of blunt force trauma from an event such as a fall, but can also result from hypertensive disease, ruptured or dissecting aneurysms, tumors, blood vessel malformations and abnormalities, and hemorrhagic conversion of ischemic stroke or venous thrombosis. Current smoking, excessive alcohol consumption, hypertension, advanced age, diabetes, illicit drug use, vascular disease, coagulopathy, a prior ICH or myocardial infarction, and platelet dysfunction can contribute to ICH or its severity.

Because ICH can be due to a variety of etiologies or even a combination of factors, it is important in evaluating a lawsuit alleging ICH to thoroughly explore the reasons a particular patient may have developed bleeding and the evidence supporting or refuting the contention that a preventable event was the proximate cause of the ICH.

Identifying Specific Signs, Symptoms, and Complications Associated with the Liability of Intracranial Hemorrhage

Many senior living and long-term care residents are prone to falling due to the progression of underlying disease, impaired mobility, balance, spatial awareness, judgment, memory, and medication issues that make them more prone to bleeding when they fall.  The use of anticoagulation therapies further increases the risk of hemorrhage and complications after a fall, as well as increasing the risk of spontaneous intracranial hemorrhage.

Fall risk assessment must be done on admission, and regularly thereafter, especially following a significant change in medication or condition.  The chart must include documentation of assessments, care plans, interventions, and changes as indicated.  Because the use of blood thinners further increases a patient’s risk, this should be clearly documented in the chart.  Even if a fall was unavoidable or occurred in the absence of any negligence, a facility may be held liable unless staff timely and thoroughly observed and assessed the resident, notified the family/physician, monitored the resident’s condition, recognized signs and symptoms of a serious injury, timely transferred them for evaluation and treatment as needed, and appropriately treated the resident post fall.  Medication errors, failure to follow physician orders, and failure to address dietary impacts on medication may also create potential liability exposure.

With ICH, prompt recognition of changes in mental status or vitals may be critical, and patients on blood thinners warrant additional monitoring for signs and symptoms of a brain bleed. A thorough evaluation should include timely neuro checks documenting any change in mental status, vitals, and pupillary responses.  The article co-authored by Dr. Sean Polster describes some specific signs, symptoms, and complications associated with ICH, including seizures, fever, hyperglycemia, and hypertension.  Caregivers observing these symptoms after a fall should be aware of a potential bleed.

Lifesaving, but Potentially Life-Threatening: Anticoagulation Therapy

Blood thinners are lifesaving but can be life-threatening, with significant risks for injury or death.  Anticoagulation and antiplatelet medications can exacerbate bleeding from a fall and increase the risk of spontaneous ICH, with larger hematomas and elevated risk of mortality.  Oral anticoagulant-associated ICH (OAT-ICH) has increased over the past several decades given increased use of these anticoagulant medications, and OAT-ICH is now responsible for nearly one quarter of all ICH.

Blood thinners also increase the risk of potential claims and suits due to alleged service failures, including:

• failure to start, adjust, discontinue, or restart medication
• mislabeled medication
• mistakes in obtaining, transcribing, reading, or following orders
• excess doses or missed doses
• failure to realize or inform the patient that certain medications, supplements, or dietary choices may exacerbate the effects of anticoagulants
• failure to timely obtain or follow orders for blood tests at regular intervals to ensure the patient’s clotting rate is within a therapeutic range
• failure to follow up on a patient’s non-compliance with orders to use anticoagulants, obtain testing, and report changes in medications, diet, or symptoms
• failure to monitor the patient and recognize signs and symptoms of an adverse reaction, which may include bruising; bleeding; blood in the stool, urine, or vomit; headache; chest pain; stomach pain; dizziness; or sudden weakness
• failure to assess and monitor a patient on blood thinners after a fall
• failure to timely recognize, report, and treat signs and symptoms of a brain hemorrhage
• improper administration of a neutralizing antidote or a clotting factor to reverse the effect of a blood thinner

Mitigating Risk Factors to Reduce the Risk of Litigation

The injuries associated with falls and anticoagulation therapy can be severe, the defense costs can be significant, and the damages can be high.  Thus, it is critical for healthcare providers and their counsel to mitigate risk factors for falls that may contribute to head injury, understand the signs, symptoms, and treatment options for intracranial hemorrhage, question the timing and etiology of a brain bleed, recognize the risks associated with the use of blood thinners, and reduce the risk of litigation.

Develop a Winning Defense Strategy with Excelas’ Experience, Expertise, Analyses, and Proprietary Tools

Excelas has experienced health information management, allied health, and nursing professionals to assist with the analysis of falls, anticoagulation use, and overall care by organizing the medical records and other relevant materials, evaluating the quality and completeness of the medical records and identifying relevant facts, preparing  medical chronologies and case summaries, identifying strengths and weaknesses, and delivering the medical records and medical analyses though a secure, cloud-based system.

Contact Excelas to learn more about our full range of services.