An Annandale nursing home resident developed internal bleeding and died after being denied crucial blood-thinning medication for 15 days, according to a state investigation that blamed the death on the facility’s procedural shortcomings.

The state Health Department’s investigation into the stroke patient’s Nov. 28 death concluded that the nonprofit Annandale Care Center “had no system, policies or procedures in place” to ensure that certain medications and some other services were being provided as prescribed.

In response to the finding of neglect, the home revised its policies concerning the administration of blood-thinning medication, reviewed the records of residents who receive that type of medication and briefed staff on proper procedures, the report said.

In a statement to the Star Tribune, the home’s administrator, Deb Reitmeier, said: “The safety and well-being of residents is our number one priority and we are committed to providing them with the highest quality of care. We have implemented additional safeguards to our medication management, conducted staff training on those safeguards and consistently conduct audits of our residents who are prescribed Coumadin to reduce any potential risk for harm.’’

The care center has the right to appeal the finding of neglect.

The Health Department said a nurse discovered that the resident’s doses of Coumadin, a blood-thinning medication, had been stopped without a doctor’s order. A required dosage test had not been performed, and that missing information triggered an automatic entry in the resident’s electronic medication record for the drug’s administration to be halted.

By the time the resident resumed receiving that drug in concert with another one, 15 days later, bleeding began on the abdominal wall accompanied by “weakness, confusion, hallucinations and vomiting,” the publicly disclosed portion of the investigation read.

Despite treatment at one hospital and then another, the resident died about two weeks after the medication error was discovered, the report said.

As is practice, the Health Department did not disclose the resident’s identity.