A lawsuit filed against a California nursing center Wednesday serves as a warning for providers to be cautious when administering medications during a shift change.

Attorneys claim that the Bella Vista Transitional Care Center dispensed too much insulin to former resident Kathleen Hutchinson, contributing to her death last year. The 85-year-old diabetic allegedly received four doses of the drug in as many hours, and staff did not relay key care information during a shift change.

Najib Yamak, operations manager for the San Luis Obispo, CA, nursing facility, disputed those accusations. He declined to comment specifically on the patient, but said the facility has protocols in place to ensure that meds are dispersed in a “clinically appropriate manner.”

“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,” he said in a statement.

Hutchinson first entered the SNF in August 2017, diagnosed with diabetes, dementia and other diseases. Doctors reportedly ordered caregivers to check her blood sugar daily and administer insulin as needed. In April 2018, her blood sugar spiked, and the physician allegedly ordered staff to increase check-ins to every hour and base shots on each reading.  

However, the family claims caregivers administered insulin hourly without properly checking levels. A shift change also occurred during that period, and staffers allegedly failed to relay important care information to the morning staff, the lawsuit claims. Hutchinson was found unresponsive later that morning, with blood sugar levels too low to produce a reading. The family also filed a complaint with the California Department of Health and Human Services, which substantiated the allegations.  

Management has changed since the alleged incident, a Bella Vista representative told KSBY. The center also disputed allegations in the suit that it is inadequately staffed.