The resident was a 73 year old man who was a long-time diabetic who was cognitively intact and had a good understanding of how his diabetes should be managed. He was transferred into the facility on October 17 from another nursing home. On admission, there was an order in place for sliding scale insulin. This admitting order was adjusted by his attending physician two days after admission. The records indicate that this regimen was followed by the staff without any evidence of adverse effects.
On November 5, the resident was seen by a nurse practitioner who was employed by an outside company – not by the doctor, not by the nursing home. The nurse practitioner ordered the insulin regimen that the doctor had ordered discontinued and a new regimen put into place. The doctor was not notified of the changes made in the insulin regimen. On November 6, the resident complained of having blood in his urine social services. There was no record of that in the nurse’s notes and no indication that the doctor had been notified. On November 7, the nurse practitioner again changed the insulin regimen – and again the doctor was not notified of the changes in the insulin regimen. That same day, the doctor also issued an order for a change in the sliding scale regimen. The difference between the two regimens was essentially that the resident would receive higher doses of insulin when the resident has lower blood sugar level readings.
From November 5 through November 10, the nursing staff followed the sliding scale regimen put in place by the nurse practitioner, not the doctor, and never resolved the differences between the two sliding scale orders. As a result, the resident received higher doses of insulin at lower blood sugar levels which would have the effect of further depressing his blood sugar levels. There was nothing in the chart to suggest that the nurses were monitoring his response to the new sliding scale orders or determine why the resident was experienced below normal blood sugar levels.
On the morning of November 10, the resident was found unsresponsive with a blood sugar level of 12, a very low level. 911 was called and the resident was given an injection of glucagon which is intended to treat severe hypoglycemia, or low blood sugar. The resident coded while the paramedics were working on him and was taken to the hospital with the paramedics continuing to administer CPR. At the hospital, he was diagnosed with respiratory failure secondary to severe hypoglycemia and cardiac arrest. He was also diagnosed with severe sepsis due to a urinary tract infection. He was placed on a ventilator and died after the family consented to the removal of the ventilator.
The investigation by IDPH into this incident revealed several disturbing findings:
- The nurse practitioner kept a separate set of notes on his treatment of the resident which were kept on his own computer which was not networked into the computer system of the nursing home or even able to be printed at the nursing home. The chart is an important communication tool among the various health care professionals involved in the care of the resident. There were no systems in place to ensure that the nurse practitioner’s notes were included in the resident’s chart.
- He was unable to justify to the surveyor the orders he entered for ordering insulin to be given to the resident at lower blood sugar levels and told the surveyor that he was thinking an error occurred, but that the nurses should have known better than to follow his order.
- The nurses here failed to resolve the inconsistencies between the orders given by the nurse practitioner and the doctor on November 7.
- The nurse practitioner agreed that infections can cause a fluctuation in blood sugar levels. The fact that the resident had blood in his urine was never addressed by anyone caring for the resident. The doctor was not notified, and the nurses appear to have been unaware of the blood in the resident’s urine that he reported to social services. The resident was suffering for severe sepsis when he arrived at the hospital. The resident also had some cellulitis on his finger for which the nurse practitioner ordered an antibiotic. The role of this infection in affecting the resident’s blood sugar levels appears to have never been considered.
- The most concerning findings come from the interview of the resident’s doctor, in part because he is also the medical director of the nursing home. He stated that he nurse practitioner is in the facility every day, but he is not privy to the orders that the nurse practitioner entered regarding his resident unless the facility tells him, which they do not always do. He sent his nurse to the nursing home for a meeting to discuss this, and the facility refused to give her access to the medical records regarding his patients.
- The doctor further described when he rounds at the nursing home, he is accompanied by a nurse from the facility who is not always the nurse who cares for a resident and is often unfamiliar with the resident.
- The doctor related to the inspector that he had standing orders regarding diabetes management, but the nurses don’t follow them. When the inspector asked the facility’s director of nursing for a copy of the doctor’s standing orders, she could not find a copy. She had to have the doctor’s office fax a copy over after the inspector asked.
- When he was asked about nurses giving insulin to residents with low blood sugar, the doctor stated that the facility has nurses on staff who don’t follow standards of practice and that the facility uses agency nurses who are not familiar with the residents and as a result there are a lot of problems with continuity of care.
This is one of the more damning citation reports I have read, which is revealing a whole series of systemic problems with how this facility is operated. The fact that some of the harshest criticisms are coming from the medical director of the facility is eye-opening and reveals some deep dysfunction about how the facility is operated.
In the end, this resident died because his insulin regimen was mismanaged. On the surface, this is a simple story to understand. Looking at this incident on a deeper level, there were a whole series of failures which shows how the way in this nursing home is managed ended with this result. One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary injuries and illnesses and wrongful deaths of residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. 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.
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