A SLO nursing home patient died from low blood sugar. Family says she was over-medicated
A San Luis Obispo transitional care facility is facing a wrongful death lawsuit after a diabetic patient died, allegedly because staff gave her too much medication.
The civil lawsuit, filed in San Luis Obispo County Superior Court on Wednesday, claims Bella Vista Transitional Care Center patient Kathleen Hutchinson, 85, died in April 2018 after she received four doses of diabetes medication during a three-and-a-half-hour period.
Civil complaints provide only plaintiffs’ perspectives — they don’t detail events from defendants’ points of view.
Hutchinson suffered from dementia, hypertension, hyperlipidemia and diabetes. She was a patient at Bella Vista for about eight months prior to her death and relied on facility staff for help with nearly all of her daily living activities, according to the lawsuit.
On the day of her death, Hutchinson’s blood sugar was taken at 5:35 a.m. and was found to be dangerously high, prompting a doctor to order 10 units of insulin be administered. Hutchinson’s blood sugar was to be rechecked an hour later.
At 6:06 a.m., additional insulin was administered per Hutchinson’s typical medication schedule, in spite of the fact she’d received a previous dose about half an hour before.
Hutchinson was given more insulin at 7 a.m. after a staff member told the doctor a blood sugar reading taken at 6:06 a.m. showed her levels were still too high.
She was then given a dose of Metformin, a diabetes medication taken in conjunction with insulin, at 8 a.m., per her typical schedule.
At 9:40 a.m., Hutchinson was found not breathing and covered in vomit. Her blood sugar was so low the blood sugar monitor couldn’t read it. Two minutes later, she was pronounced dead.
The lawsuit claims Hutchinson died because staff followed her usual medication schedule on top of doctor-specified doses tailored to her condition the morning of her death.
Understaffing allegations and administrative turnover
“What happened here was not one small human error mistake, but one big mistake by several people, ” said Greg Johnson, a Thousand Oaks attorney representing Hutchinson’s family.
These errors occurred due to Bella Vista’s understaffing issues and administrative turnover, according to the complaint. The facility had four different administrators during Hutchinson’s eight months as a patient at Bella Vista.
A Department of Public Health (DPH) investigation into Bella Vista following Hutchinson’s death concluded the facility “(failed) to meet the professional standards of quality in providing care pursuant to care plans and treatment orders,” according to the lawsuit.
DPH also previously cited Bella Vista for failing to meet minimum staffing requirements, failing to ensure call lights were in reach of residents, failing to provide showers and asking certified nursing assistants to perform nursing assessments beyond their scope.
Najib Yamak, Bella Vista operations manager, said he could not answer questions about Hutchinson’s care, citing privacy laws.
“I can confirm that Bella Vista generally has protocols in place relative to medication administration to ensure that this process is carried out in a clinically appropriate manner and consistent with the existing orders of the resident’s physician,” Najib wrote in an email.
“Bella Vista is committed to person-centered care, and that commitment extends to all phases of a resident’s stay, including but not limited to the administration of medication. In addition, the facility staffs to meet the needs of its residents, taking into account the number of residents in the building and resident acuity. We believe that our approach to staffing is fully compliant with industry-specific standards and regulations, and respectfully but earnestly disagree with any suggestion of inadequate or underqualified staff.”
