This month we look at a case involving several errors that led to the death of a patient. The case went to trial and resulted in a verdict for the plaintiff that included punitive damages. The defendants appealed, and the Court of Appeals was asked to decide whether punitive damages were appropriate.

The patient, Mr K, experienced a stroke in his mid-80s that resulted in memory problems and the inability to manage his own medications or walk without assistance. Mr K had diabetes for which he took insulin. After 2 years of caring for Mr K at home with the help of nurses, his family decided that he needed more supervised care than they could provide.

When Mr K was aged 87 years, he was moved into The Pines, a facility that provided memory care. The facility did not request a physician’s medical assessment or admission order prior to admitting Mr K. The patient had been treated at a VA hospital previously, and there was some confusion as to who his primary care physician was. Mr K’s family provided a list of his medications, which included insulin glargine and insulin aspart. However, the facility had difficulty verifying the list as no primary physician was identified. The facility assigned one of its contracted physicians to be Mr K’s attending physician.

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Due to the confusion regarding his medication regimen, Mr K’s son stayed with him at the facility the first night to monitor his blood sugar levels and administer his medications. The next morning, Mr K’s son checked the patient’s blood glucose, gave him his medication, and took him to a scheduled appointment at the VA hospital. Upon returning to The Pines, Mr K’s son checked his father’s blood sugar levels again and administered his medication. He then left his father in The Pines’ dining room for lunch.

After lunch, Nurse B checked the patient’s blood sugar level, which showed elevated readings of 358 mg/dL and 398 mg/dL. Concerned, she called Nurse Practitioner (NP) A, who worked with the physician who had been assigned to Mr K. Neither NP A nor the physician had seen Mr K, yet NP A gave a medication order over the phone, changing Mr K’s regimen. She discontinued the insulin glargine and insulin aspart, and instead ordered metformin and insulin detemir twice daily. The new medication regimen meant that the patient went from receiving 10 units of insulin daily to 55 units daily. The facility notified Mr K’s family that the brand of insulin had changed, but the family was not told about the addition of metformin or that the insulin dosage had been changed.

Mr K began experiencing episodes of hypoglycemia on the new regimen. Two days after the medication change, Nurse B found Mr K’s blood sugar level to be 51 mg/dL. She did not contact the assigned physician or NP A; instead, she gave Mr K orange juice. When that failed to increase his glucose level, she administered oral glucose. After the glucose was given, Mr K’s blood sugar level rose to 186 mg/dL. At 2:00 AM the following morning, Nurse B found Mr K incoherent. She noted that verbal stimuli and a sternum rub elicited no response, and he had pinpoint pupils. According to Nurse B’s notes, Mr K’s blood sugar level was 52 mg/dL at that time. She wrote in the chart, “Oral glucose gel was given. After 10 minutes, retook finger stick. Blood sugar was 48. After waiting 5 minutes, remeasured blood sugar, 28.” Nurse B called for an ambulance. Upon arrival, emergency medical technicians administered glucose intravenously.

Mr K died at the hospital the next day.

Mr K’s family sued the facility, the company that provided the contracted physicians and NPs, and several others. The case went to trial before a jury who decided in favor of Mr K’s family and awarded a small amount of compensatory damages (approximately $5,000) as well as $100,000 in punitive damages. The facility appealed.