The Tribune (SLO) - - Front Page - BY LIND­SEY HOLDEN

A wrong­ful death law­suit al­leges Bella Vista Tran­si­tional Care Cen­ter gave a patient too much di­a­betes medication.

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.


“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.”

Lind­sey Holden: 805-781-7939, @lind­seymholden

DAVID MIDDLECAMP dmid­dle­[email protected]­bune­

Bella Vista Tran­si­tional Care Cen­ter in San Luis Obispo is fac­ing a wrong­ful death law­suit af­ter a di­a­betic patient died, al­legedly be­cause staff gave her too much medication.

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