River Hills Rehab: Insulin Withheld 6 Days - TX
The resident's blood sugar spiked to 446 mg/dL before her family member called the facility to ask why she wasn't receiving insulin. Only then did nursing staff discover the omission and contact her physician.
Federal inspectors declared the medication failure an immediate jeopardy to resident health on February 7, citing the facility's failure to provide pharmaceutical services to meet residents' needs.
The resident was admitted January 30 following hospitalization for a urinary tract infection and new-onset congestive heart failure. Her discharge instructions clearly listed 17 units of insulin glargine to be administered once daily. She had been managing her diabetes for years and administered her own insulin at home.
But nursing staff never entered the insulin order into the facility's electronic medical record system.
For nearly a week, no one checked her blood glucose levels. When testing finally began February 5, her reading hit 233 mg/dL that evening. The next morning, it had climbed to 446 mg/dL — nearly four times the normal range.
"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," the resident told inspectors on February 6. She said she felt fine and was pleased correct orders were finally in place.
The family member's intervention came February 5. Licensed Vocational Nurse G told inspectors she received the call from the resident's relative asking about the insulin. Only then did she check the hospital discharge medication list and discover the admitting nurse had failed to transcribe the insulin order.
LVN G contacted the resident's physician at 4:30 PM that day to obtain the missing orders.
Director of Nursing AG confirmed to inspectors that the resident had gone without insulin from January 31 through February 5, placing her at risk for hyperglycemia with both short-term and long-term effects. The DON said she expected all nursing staff to confirm discharge instructions and transcribe them to the electronic medical record to ensure medication administration.
The facility's own policies required exactly that process. Its medication reconciliation policy, revised in July 2017, specified that admitting nurses should reconcile discharge medications including dose, route and frequency, notify the physician to verify orders, and transcribe them to the electronic medical record.
Administrator confirmed the facility had failed to provide necessary medication per physician's orders and said she expected nursing staff to follow those orders.
Two physicians offered different perspectives on the missed doses. The resident's current physician, MD #1, said he didn't anticipate adverse effects since her blood sugar levels were similar to those during hospitalization. He praised the facility's quick action once the error was discovered.
The admitting physician, MD #2, said he wasn't concerned about the missed insulin doses because the long-acting medication stays in the system 36 to 40 hours. He said sliding scale protocols weren't typically recommended for that type of insulin anyway.
But the resident's dangerously elevated blood sugar told a different story. After receiving her first insulin dose on February 5, her blood glucose level dropped to 219 mg/dL by February 7 — still elevated but significantly improved.
Federal inspectors found the medication error represented a systemic breakdown in admission procedures. The facility had policies in place but failed to follow them consistently.
The immediate jeopardy citation triggered an extensive remediation effort. The medical director was notified February 7, and the director of nursing completed admission drug regimen reviews for all recent admissions dating back to January 30.
Facility leaders created a tracking system for admission medication reconciliation and conducted audits to ensure medication availability for all residents. They implemented daily clinical meetings to monitor the process Monday through Friday, with weekend coverage by the DON or designee.
All 27 full-time and part-time nurses received mandatory education on medication reconciliation, change of condition protocols, and physician notification requirements. Eight agency nurses also completed the training.
During interviews February 8, nursing staff demonstrated understanding of the corrected procedures. LVN H told inspectors she understood the importance of accurate medication reconciliation for new admissions. RN I said she knew how to input orders into the electronic medical record and identify changes in resident condition.
LVN J emphasized the importance of verifying admitting orders with physicians, while LVN C said she understood the significance of proper medication reconciliation after receiving the mandatory training.
The facility established ongoing monitoring through daily clinical meetings and monthly quality assurance reviews. An ad hoc quality committee meeting was held February 7 to address the immediate jeopardy finding.
Federal inspectors removed the immediate jeopardy designation February 8 after verifying the facility's corrective actions. However, River Hills remained out of compliance at a lower severity level while inspectors evaluated the effectiveness of the new systems.
The case highlighted broader concerns about medication management during nursing home admissions. The resident's six-day gap in insulin therapy occurred despite clear discharge instructions and established facility policies designed to prevent such errors.
The resident's experience underscored the critical role family members often play in catching facility mistakes. Without her relative's phone call questioning the missing insulin, the medication error might have continued indefinitely.
Her blood sugar readings during those six days without insulin demonstrated the real health risks of medication reconciliation failures. The spike to 446 mg/dL represented severe hyperglycemia that could have triggered diabetic complications requiring emergency intervention.
The facility's response, while comprehensive, came only after federal inspectors identified the immediate jeopardy. The extensive training and monitoring systems implemented in February raised questions about why such safeguards weren't already in place for a basic admission requirement.
River Hills' medication reconciliation breakdown reflected a pattern inspectors see repeatedly in nursing facilities nationwide. Despite federal requirements and facility policies, the critical step of accurately transcribing hospital discharge orders continues to fail residents who depend on precise medication management for their health and survival.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
RIVER HILLS HEALTH AND REHABILITATION CENTER in KERRVILLE, TX was cited for violations during a health inspection on February 8, 2025.
The resident's blood sugar spiked to 446 mg/dL before her family member called the facility to ask why she wasn't receiving insulin.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.