KERRVILLE, TX - Federal inspectors issued immediate jeopardy citations to River Hills Health and Rehabilitation Center after discovering that staff failed to administer prescribed insulin to a diabetic resident for six consecutive days, causing potentially life-threatening blood sugar elevations.
Critical Medication Error Discovered
The February 8, 2025 inspection revealed that the facility's admitting nurse failed to reconcile insulin orders from hospital discharge instructions when Resident #1 was admitted on January 30. The oversight left the diabetic resident without her prescribed 17 units of daily Insulin Glargine from January 31 through February 5.
The error was only discovered when the resident's family member contacted facility staff after the resident mentioned she hadn't received her insulin medication. By that time, the resident's blood glucose had reached 446 mg/dL on February 6 - nearly three times the normal range of 80-130 mg/dL for diabetics.
Dangerous Blood Sugar Elevations
Blood glucose monitoring revealed the severity of the situation. After missing insulin for six days, the resident's levels spiked dramatically: - February 5: 233 mg/dL - February 6 morning: 446 mg/dL - February 6 evening: 274 mg/dL
These readings indicate severe hyperglycemia, a condition that can lead to diabetic ketoacidosis - a potentially fatal complication where the body begins breaking down fat for energy, producing toxic acids in the blood.
How the Error Occurred
The medication error originated during the admission process on January 30. Hospital discharge instructions clearly listed the insulin order, but the admitting nurse failed to transcribe it into the facility's electronic medical record system. This breakdown in medication reconciliation - a critical safety process designed to prevent exactly this type of error - went undetected for nearly a week.
LVN G, who eventually discovered the error on February 5, confirmed that the hospital discharge medication listing included the insulin order that the admitting nurse had missed. The Director of Nursing acknowledged that the resident "had not received insulin for 6 days from 01/31/25-02/5/25, putting her at risk for hyperglycemia with both short-term and long-term effects."
Medical Risks and Consequences
Insulin Glargine is a long-acting insulin that helps maintain baseline blood glucose levels throughout the day. When diabetic patients miss this medication, several serious complications can develop:
Immediate risks include severe dehydration, increased urination, and diabetic ketoacidosis. Long-term consequences of uncontrolled blood sugar include damage to blood vessels, kidneys, eyes, and nerves.
The resident's attending physician expressed concern about the blood sugar spike, immediately ordering rapid-acting insulin to bring levels down and implementing enhanced monitoring protocols.
Facility Response and Corrections
Upon discovery of the immediate jeopardy situation, River Hills Health implemented comprehensive corrective measures:
Immediate Actions: The Medical Director was notified, and staff completed chart audits on all 12 residents receiving insulin. An insulin tracking system was established with daily monitoring by the Director of Nursing or designee.
Staff Education: All 35 nursing staff members (27 full-time/PRN staff and 8 agency nurses) received immediate training on medication reconciliation procedures. The training emphasized the critical importance of verifying all discharge orders and transcribing them accurately into the electronic medical record.
Enhanced Monitoring: The facility created an admission drug regimen review and reconciliation tracker, with daily oversight during clinical meetings Monday through Friday and weekend monitoring by designated staff.
Industry Standards for Medication Safety
Federal regulations require nursing homes to ensure residents receive medications as prescribed and are free from significant medication errors. The medication reconciliation process is a fundamental safety requirement during admissions, designed to prevent dangerous gaps in treatment.
Industry best practices mandate that admitting nurses: - Review all hospital discharge instructions thoroughly - Verify each medication order with the attending physician - Transcribe all orders into the facility's medication system - Conduct immediate blood glucose monitoring for diabetic residents
Systemic Issues Revealed
The inspection revealed broader concerns about the facility's admission procedures. While this case involved only one resident, it highlighted vulnerabilities in the medication reconciliation system that could affect other residents.
The facility's own policies, revised in 2017 and 2019, clearly outlined expectations for medication reconciliation and administration according to prescriber orders. The failure to follow these established protocols indicates a breakdown in staff training or oversight systems.
Resident Impact and Recovery
The affected resident, who had been managing her diabetes independently at home, told inspectors she had noticed the missing insulin but initially mentioned it only to family rather than facility staff. "Resident #1 stated she told her family member yesterday that she had not received her insulin like she did at home but did not mention it to facility staff," according to the inspection report.
Fortunately, once the error was discovered and corrected, the resident's condition stabilized. She reported feeling fine and expressed satisfaction that proper orders were in place.
Regulatory Consequences
The immediate jeopardy citation was removed on February 8 after inspectors verified the facility's corrective actions. However, River Hills Health remains out of compliance at a scope of "isolated" with "no actual harm with potential for more than minimal harm," requiring ongoing monitoring to ensure the effectiveness of implemented safeguards.
The facility must demonstrate sustained compliance with medication reconciliation procedures and continue enhanced monitoring of insulin administration to prevent similar incidents.
Implications for Nursing Home Safety
This case underscores the critical importance of robust admission procedures and medication reconciliation systems in nursing homes. The six-day delay in discovering a missing insulin order highlights how communication gaps between residents, families, and staff can compound medication errors.
The incident serves as a reminder that even brief interruptions in diabetes management can create serious health risks, particularly for elderly residents who may be less able to advocate for themselves or recognize symptoms of uncontrolled blood sugar.
River Hills Health's comprehensive response, including staff retraining and enhanced monitoring systems, demonstrates the facility's commitment to preventing similar incidents and ensuring resident safety moving forward.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Hills Health and Rehabilitation Center from 2025-02-08 including all violations, facility responses, and corrective action plans.
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