California Nursing Home Resident Dies after Alleged Over-Medication Error
A resident in a California nursing home who suffered from dementia, hypertension, hyperlipidemia, and diabetes died after receiving four doses of diabetic medication during a three and one-half hour period.
At 5:35 a.m. on the morning the resident died, a reading taken to measure the woman’s blood sugar found it to be dangerously high. A doctor ordered that the resident be given 10 units of insulin and instructed staff to re-check the resident’s blood sugar in an hour. However, at 6:06 a.m. the resident was given her normal dose of insulin without taking into consideration that she had been given the previous dose only a half hour earlier. At 7 a.m. the doctor was informed that the resident’s blood sugar reading was still too high—that reading had been taken at 6:06 just thirty minutes after the doctor had ordered the 10 units of insulin to be given. At 8 a.m., the resident was given her regular dose of Metformin—a diabetes medication that is given in conjunction with insulin.
The resident was found at 9:40 a.m. not breathing. She had vomited, and her blood sugar was so low the monitor couldn’t read it. She was pronounced dead two minutes later.
The lawsuit claims that the resident died as a result of the facility staff administering her usual medication without taking into consideration the doctor’s orders for additional insulin in response to the resident’s elevated blood sugar.
The lawsuit also alleges that the errors were related to understaffing and administrative turnover issues at the facility.
Compliance Perspective
Failure to consider how a physician’s new medication orders addressing a change in a resident’s condition might affect orders already in place can result in over-medication, immediate jeopardy, and substandard quality of care in violation of federal regulations.
Discussion Points:
- Review policies and procedures for medication management to prevent over-medication when new orders address changes in a resident’s condition but may also impact the regular medication regimen, e.g., diabetic residents and additional insulin administration.
- Train nursing staff to watch for potential medication errors, like over-medication, when a physician issues an order in response to a resident’s change in condition and staff also administer the resident’s same class of regular medications, e.g., diabetics and insulin administration.
- Periodically audit residents’ medication orders to determine if there is any evidence of over-medication or potential negative interactions.
