KERRVILLE, TX - River Hills Health and Rehabilitation Center was placed under immediate jeopardy status following a February 8, 2025 inspection that revealed systematic failures in insulin administration and laboratory testing protocols that placed residents at serious risk of medical complications.
Insulin Administration System Breakdown
Inspectors identified critical deficiencies in how the facility managed insulin medications for diabetic residents. The investigation centered on Resident #1, whose case revealed multiple layers of medication management failures that prompted regulators to issue the most serious classification available under federal nursing home oversight.
The facility failed to administer Insulin Glargine according to hospital discharge instructions and did not provide fast-acting insulin as ordered by the resident's physician. Insulin Glargine is a long-acting insulin that helps control blood sugar levels throughout the day and night, while fast-acting insulin addresses immediate blood sugar elevations, particularly after meals.
The consequences of improper insulin administration can be severe and immediate. When long-acting insulin is not given as prescribed, blood sugar levels can rise dangerously high, potentially leading to diabetic ketoacidosis—a life-threatening condition. Conversely, incorrect timing or dosing of fast-acting insulin can cause blood sugar to drop too low, resulting in hypoglycemia that can lead to confusion, loss of consciousness, seizures, or even death.
Medical protocols require precise timing and dosing of insulin medications. Long-acting insulin typically must be administered at the same time each day to maintain stable blood sugar control, while fast-acting insulin must be coordinated with meals. The facility's failure to follow hospital discharge instructions meant that the resident's carefully calibrated diabetes management plan was not being implemented as designed by the hospital's medical team.
The immediate jeopardy determination was communicated to the facility's Medical Director on February 7, 2025. In response, the Director of Nursing conducted an audit of all residents receiving insulin that same day and implemented an insulin tracker requiring daily monitoring to ensure correct and timely administration.
Widespread Staff Training Deficiencies
The investigation revealed that multiple nursing staff members required re-education on fundamental insulin administration protocols. On February 7, 2025, the Vice President of Clinical conducted emergency training sessions with the Director of Nursing and Assistant Directors of Nursing regarding insulin order audits, administration competency, and glucometer usage.
Staff who were not physically present at the facility during the inspection were contacted by phone to receive the mandatory education. The facility employed 27 full-time and per diem nurses, plus 4 agency nurses, all of whom required verification of their understanding of proper insulin protocols.
During follow-up verification on February 8, 2025, inspectors interviewed 17 of the 27 full-time and per diem nursing staff, plus all 4 agency nurses on duty. Each staff member was required to verbalize their understanding of how to transcribe insulin orders, enter insulin parameters into the electronic medical record system, document administration properly, and recognize when to notify physicians about concerning blood sugar levels.
Standard nursing practice requires that any nurse administering insulin must understand the difference between long-acting and short-acting formulations, know how to interpret blood glucose readings, recognize signs of both high and low blood sugar, and understand the timing requirements for different insulin types. The need for facility-wide re-education suggested these fundamental competencies had not been consistently maintained.
Laboratory Testing Protocol Failures
Beyond the insulin management issues, inspectors documented that the facility failed to obtain ordered laboratory services for Resident #2. The resident, who was admitted with multiple conditions including depression and cognitive communication deficit, experienced confusion, agitation, and sleep disturbances on August 30, 2024.
When the resident's condition changed, a registered nurse contacted the physician and received a verbal order for a urinalysis with culture and sensitivity testing—a standard diagnostic test used to identify urinary tract infections. However, the nurse never entered the order into the facility's electronic system, and the urine specimen was never collected or sent to the laboratory for analysis.
Urinary tract infections are particularly problematic in elderly residents with cognitive impairments. Symptoms often manifest as increased confusion, agitation, or behavioral changes rather than the typical burning sensation or urgency that younger adults experience. The ordered test was specifically designed to determine whether the resident's sudden cognitive and behavioral changes were caused by a treatable infection.
The resident care plan specifically included interventions to monitor for signs of urinary issues, instructing staff to report burning on urination, fever, pus in urine, blood in urine, or foul-smelling urine to the physician. Despite this documented care plan requirement and the physician's explicit order for testing, the laboratory work was never completed.
The facility's Assistant Director of Nursing stated during interviews that she was instructed to complete a skin assessment on the resident but was unaware the urinalysis order had not been entered into the system or monitored. The registered nurse who received the verbal order left employment approximately two weeks after the incident, stating the workload was difficult to manage.
Medical Significance of Testing Delays
Delayed or missing laboratory testing can have serious medical consequences. Urinary tract infections in elderly residents can progress rapidly if untreated, potentially leading to kidney infections, sepsis, or permanent kidney damage. The bacteria causing the infection can enter the bloodstream, creating a systemic infection that may require hospitalization and intensive antibiotic treatment.
Culture and sensitivity testing is particularly important because it identifies not only whether bacteria are present, but also which specific antibiotics will be effective against the particular strain causing the infection. Without this information, physicians must prescribe antibiotics empirically, potentially using medications that may be less effective or contribute to antibiotic resistance.
The resident was eventually hospitalized on September 8, 2024—nine days after the urinalysis was initially ordered—for an unrelated condition. During that hospitalization, medical staff performed a urinalysis that confirmed the presence of a urinary tract infection, which was then treated with antibiotics. Had the testing been completed when originally ordered in August, the infection could have been identified and treated weeks earlier in the nursing home setting, potentially preventing the progression of symptoms.
Systemic Oversight Weaknesses
The violations revealed fundamental weaknesses in the facility's order management and follow-through systems. When physicians issue orders—whether verbally by telephone or in writing—nursing homes are required to have reliable processes to ensure those orders are documented, entered into medication administration systems, and carried out as prescribed.
Best practices in nursing home medication management include multiple verification checkpoints. Orders should be reviewed by nursing supervisors, pharmacists should verify medication orders before dispensing, and administrative staff should conduct regular audits to identify any gaps between what physicians ordered and what is actually being administered.
The facility's response plan included implementing daily reviews of order listings during morning clinical meetings, conducting insulin administration competency observations for all nursing staff, and presenting insulin monitoring data at monthly Quality Assurance and Performance Improvement committee meetings for at least three months.
Federal regulations require nursing homes to provide pharmaceutical services to meet the needs of each resident, including procedures to ensure medications are administered as ordered and that appropriate laboratory monitoring occurs. The facility's failures represented violations of these fundamental care requirements.
Additional Issues Identified
The inspection also documented the facility's lack of systematic processes for monitoring telephone orders received from physicians. The facility's own policy stated that verbal telephone orders must be reduced to writing by licensed personnel and recorded in the resident's medical record with instructions, date, time, and signature of the person transcribing the information.
The policy further required that telephone orders be countersigned by the physician during the next visit. However, the policy did not address what should happen when orders were received but never entered into the electronic system—a gap that allowed the urinalysis order for Resident #2 to be completely lost.
After the immediate jeopardy was identified, the facility implemented multiple corrective measures including an insulin tracker log reviewed daily by the Director of Nursing or designee, mandatory competency training for all nurses before their next shifts, and daily audits to confirm insulin orders were properly transcribed and administered according to physician specifications.
The immediate jeopardy designation was removed on February 8, 2025, at 7:37 PM after inspectors verified that corrective systems were in place and functioning. However, the facility remained cited for violations at a lower severity level while regulators continued monitoring the effectiveness of the new protocols. Inspectors verified proper insulin administration through direct observation and confirmed that all nursing staff could verbalize correct procedures for managing insulin orders and recognizing when to alert physicians about concerning blood sugar readings.
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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