The Illinois Department of Health has cited and fined Generations at Regency in Niles, Illinois when nursing staff failed to properly treat and monitor a diabetic resident experiencing dangerously low blood sugar for nearly three hours, during which time no physician or nurse practitioner was ever notified. The resident was ultimately transported to the hospital in respiratory distress and unresponsive, where he died that same day.
A 60-year-old resident at Generations at Regency had a long and complex medical history, including end-stage renal disease requiring dialysis, Type II diabetes, congestive heart failure, and several other serious conditions. In the early morning hours of what would become his final day at the facility, the night shift nurse entered his room and found him in an alarming state. As the nurse later described it, “I noted the resident was not at his baseline, and I had to vigorously shake him to get him to arouse.” When she checked his blood sugar, it was 42 mg/dl — far below the 70 mg/dl level that triggers required intervention under both the facility’s own policies and national medical guidelines.
The nurse administered an emergency dose of glucagon, a medication used to rapidly raise blood sugar. Thirty minutes later, however, his blood sugar had barely moved, now reading 43 mg/dl. She gave another dose of glucagon and offered apple juice, which the resident was able to drink. At this point, rather than contacting a doctor or nurse practitioner, the night nurse simply handed off his care to the incoming morning shift nurse and left the building. As she explained later, “My understanding was that [the morning nurse] was going to monitor the resident and I left the facility.”
The morning nurse checked the resident’s blood sugar after receiving report and found it still critically low — below 50 mg/dl. She administered more glucagon and rechecked multiple times, but his levels stubbornly refused to climb. In her own words, “I rechecked a couple times, but it never got above 60 mg/dl.” The morning nurse gave yet another dose of glucagon and then noticed something more alarming: the resident was showing signs of labored, abnormal breathing and his respirations were dangerously low. She connected him to a continuous vital signs monitor and called a nursing supervisor for assistance.
Nearly two and a half hours had passed since the low blood sugar was first identified. It was only at this point — when the resident was already showing signs of a medical emergency — that the nurse practitioner was finally contacted. The nurse practitioner later stated plainly: “My expectation would be for the nursing staff to immediately assess the patient, give the glucagon, and notify me as they monitor the resident. I should be notified of any resident that is experiencing hypoglycemia.” The medical director was equally clear: “I would expect the nursing staff to promptly notify the attending upon any resident having a blood glucose level of 70 mg/dl or below.”
When paramedics arrived, they found the resident seated on his bed, unresponsive, with his head tilted forward. He was rushed to the hospital, where he arrived in severe respiratory distress with oxygen levels dropping into the 80s. He required immediate intubation and sedation. He died that day.
The facility’s own Hypoglycemia Management Policy required staff to remain with the resident at all times, recheck blood glucose every 15 minutes, re-treat if levels did not rise, and call 911 if the resident remained unable to swallow or respond to treatment. The facility’s Change of Condition Policy required nurses to notify the attending physician or nurse practitioner of any significant change in a resident’s health status. Neither policy was followed. The Director of Nursing confirmed that the night nurse “was terminated due to failing to follow our facility protocol,” noting she “should have notified the nurse practitioner right away when she noted the resident had low blood glucose.” The facility received an Immediate Jeopardy citation from the state — the most serious level of violation, indicating that the failure caused or was likely to cause serious injury or death.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
