KALAMAZOO, Mich, (WOOD) — At age 68, Dora Coburn wasn’t expected to stay much longer at Tendercare of Westwood nursing home in Kalamazoo Township — maybe two more weeks — because her rehab was going so well.
A hospital had sent her there two weeks earlier, in June 2013. She had lots of medical issues, including heart problems and chronic kidney disease.
The hospital also sent along a list of her allergies — bananas, codeine, iodine and penicillin.
Bananas topped the list.
But the Tendercare of Westwood nurse who transcribed her admission orders didn’t list bananas. In fact, state records show, the nurse didn’t list any allergies.
“The spot reserved for this information had been left blank,” a state investigator wrote.
Two weeks later, Coburn told the nursing home she tasted bananas in her pudding. Within an hour, her tongue was tingling. The last time she’d eaten bananas, in 1973, she was in the hospital for nine days.
This time, she did not survive.
The home gave her epinephrine, then rushed her off in an ambulance to the hospital. Three hours later, the hospital sent her back after saying her symptoms were gone.
But a half hour later, she complained she was having trouble breathing. The ambulance rushed her back to the hospital, where she died early the next morning — six hours after eating dessert.
Her physical therapist said Coburn had passed her “home safety assessment” just two days earlier and likely would have returned to her own home in two weeks.
“I am so shock(ed) that patient expired,'” the physical therapist wrote.
Her death certificate mentions nothing about the allergic reaction. It says she died after suffering for years from congestive heart failure and hypertensive and atherosclerotic cardiovascular disease, a heart disease often caused by high blood pressure.
The state investigated and found the home’s practices had placed patients in immediate jeopardy. The state fined the home $44,525 and ordered changes to make sure it didn’t happen again.
Coburn’s son, Darran Smith, of Kalamazoo, said his family is talking to an attorney and considering a lawsuit.
Nursing home administrator Carly MacDonald said she couldn’t discuss specifics, though in a written statement, she said her “staff responded quickly and appropriately at the time of the incident.” She refused to say whether the death led to discipline of any staff.
However, she said the home took steps, approved by the state and federal government, to make sure it doesn’t happen again. Here is her written statement:
“We express our condolences to the friends and family of Dora Coburn for their loss and are deeply saddened by her death. Due to federal privacy laws and out of respect for her family, we cannot discuss the specifics of her medical history or the care and services she received at our center. Our staff responded quickly and appropriately at the time of the incident and we reported this situation to the Michigan Department of Licensing and Regulatory Affairs, as required by law. The cause of death, as noted on the death certificate issued by the State of Michigan, is cited as natural causes.”
“We take the safety and well-being of our residents very seriously and the center is in compliance with all state and federal regulations.”
The home is rated as much below average in health inspections and below average in its overall rating, according to Medicare.gov. Over the last three years, the state has fined it more than $103,000.