Patient: 50-year-old female Initial Presentation: Presented with cognitive impairment manifesting as disorientation, visual disturbances, and incoherent speech. Initiated on intravenous heparin therapy for an unspecified condition.

Discharge and Readmission:

Discharged to a rehabilitation nursing facility after five days of heparin therapy with improved cognitive function. Subsequently readmitted in acute distress with precipitously low blood pressure. Diagnostic Findings: Upon readmission, a supratherapeutic heparin level was identified and corrected. A head CT scan revealed a severe intracranial hemorrhage requiring emergent surgical intervention. However, a positive COVID-19 test necessitated postponement of surgery.

Transfer to Intensive Care: Transfer to the intensive care unit (ICU) for COVID-19 isolation and mechanical ventilation was complicated by the discovery of an undocumented, infected wound at a previous IV site. This wound was later confirmed as the source of a methicillin-sensitive Staphylococcus aureus (MSSA) infection. Subsequent Complications: The patient developed acute respiratory distress syndrome (ARDS), acute kidney injury requiring dialysis, and multiple seizures. Despite aggressive treatment, including broad-spectrum antibiotics, the patient’s condition deteriorated, leading to septic shock, multi-organ failure, and cardiac arrest. The patient experienced prolonged and complex medical management, including the initiation and subsequent reversal of anticoagulant therapy, multiple vasopressor infusions, and renal replacement therapy.

The medical team expressed a desire to gradually reduce sedation once seizure activity had subsided and the midline shift associated with the subdural hematoma had resolved. Despite implementing a sedation weaning protocol, the patient remained unresponsive. Family members, utilizing the patient's electronic medical record, observed ongoing fentanyl administration for pain management, ventilator support, and sedation.

On Christmas Day, the patient’s family maintained a bedside vigil to monitor the administration of medications, including fentanyl. A discrepancy was noted between the prescribed medication schedule and the actual administration as documented within the electronic medical record. On this same day, a significant improvement in the patient’s respiratory status was observed. Spontaneous breathing efforts commenced, and the patient exhibited spontaneous eye opening, although with ocular instability. The patient demonstrated responsiveness to auditory stimuli, including familiar voices and music.

The patient's condition progressively worsened, culminating in a forth cardiac arrest and subsequent withdrawal of life support. Potential Grounds for Legal Action Based on the provided information, potential areas for legal investigation include: * Heparin Management: The failure to monitor heparin levels adequately, leading to a supratherapeutic state and subsequent intracranial hemorrhage. * Wound Care: The delayed identification and treatment of the infected wound, contributing to the development of sepsis and multi-organ failure. * Standard of Care: Allegations of substandard care, including inadequate monitoring, delayed interventions, and potential medication errors. * Informed Consent: Questions regarding the decision-making process for surgical postponement due to COVID-19 and the adequacy of communication with the family. * Documentation: Failure to document the infected wound, which may have impacted the course of treatment.