MOBILE, AL - Federal inspectors cited Knollwood Healthcare for immediate jeopardy violations after discovering that multiple residents went without critical medications for diabetes, seizures, and heart conditions during a facility-wide internet outage in January 2025.
The March 27, 2025 inspection revealed that nursing staff failed to administer essential medications to residents when the facility's electronic medication administration record (eMAR) system became inaccessible during an internet service disruption on January 21-22, 2025.
Multiple Residents Affected by Medication Failures
The inspection documented serious medication administration failures affecting residents with life-threatening conditions. Four residents specifically identified in the report experienced gaps in critical care that could have resulted in severe health consequences.
Resident with diabetes missed multiple doses of sliding scale insulin injections and long-acting insulin over a two-day period. The resident was prescribed insulin four times daily for hyperglycemia related to Type 2 diabetes with chronic kidney disease, but received none of the scheduled doses during the outage.
Resident with epilepsy went without all five prescribed seizure medications for multiple doses across the same timeframe. The resident told inspectors: "There was a few shifts that I did not receive any of my medications." This resident was prescribed Clobazam, Lacosamide, Lamotrigine, Oxcarbazepine, and Topiramate to control seizure activity.
Resident with multiple chronic conditions missed doses of blood pressure medications, heart failure drugs, blood thinners, and insulin. This included missing doses of Carvedilol for blood pressure, Furosemide for heart failure, and Rivaroxaban for blood clot prevention.
Medical Consequences and Risks
The facility's medical director explained the potential health impacts of the missed medications during a telephone interview with inspectors. For diabetes patients missing insulin doses, the physician noted that "blood sugars could go up" and residents could develop short-term diabetic ketoacidosis (DKA), potentially requiring intensive care treatment with insulin drips.
Missing seizure medications creates an immediate risk of breakthrough seizures, which can be life-threatening, particularly for residents with complex medical conditions. The medical director confirmed "there was a likelihood of reoccurrence of seizures if a resident did not receive their seizure medications as ordered."
For residents with heart failure and hypertension, missing prescribed medications could trigger fluid retention, elevated blood pressure, and recurrence of heart failure symptoms. These complications can rapidly become medical emergencies requiring hospitalization.
Blood glucose monitoring was also suspended during the outage, preventing staff from identifying dangerous blood sugar levels that would normally trigger immediate intervention. Unmonitored high blood glucose can lead to dehydration, electrolyte imbalances, and potentially life-threatening complications.
System Failures and Staff Response
The medication administration breakdown occurred when the facility's internet service failed, making the electronic medication administration records inaccessible. However, interviews with nursing staff revealed concerning gaps in emergency protocols and clinical judgment.
One registered nurse working a double shift told investigators she "was unable to pass any medications because she did not have access to residents' eMAR." The nurse stated she could only administer routine insulin doses to residents she knew from memory but could not provide sliding scale insulin or blood glucose monitoring.
A licensed practical nurse reported connecting to a mobile hotspot to continue medication administration, demonstrating that workaround solutions were available but not consistently implemented across the facility.
Another nurse explained she could not administer blood glucose monitoring because "she did not know who needed their blood glucose checked off the top of her head." This response indicates a concerning lack of familiarity with residents' critical care needs.
Regulatory Standards and Best Practices
Federal regulations require nursing homes to administer medications within one hour of their prescribed time and maintain accurate documentation of all medication administration. Facilities must have contingency plans for system outages that ensure continuous patient care.
Industry best practices include maintaining printed backup medication records, training staff on emergency protocols, and ensuring multiple methods for accessing critical patient information. The regulation violated, F760, specifically addresses medication administration safety and timing requirements.
Immediate jeopardy citations represent the most serious level of regulatory violations, indicating conditions that pose immediate risk to resident health and safety. This level of citation typically triggers enhanced oversight and mandatory corrective action plans.
Facility Response and Corrective Actions
Following the inspection, Knollwood Healthcare submitted an acceptable removal plan addressing the identified deficiencies. The facility implemented several immediate changes including monthly printing of paper medication administration records and comprehensive staff education.
All 21 nursing staff members received individual training on emergency protocols, medication administration during system outages, and the importance of maintaining patient care continuity. The facility also conducted mock drills to test emergency procedures.
The facility replaced its internet router on January 30, 2025, and established protocols for printing backup medication records in advance of forecasted severe weather or other anticipated service disruptions.
A quality assurance meeting involving the entire interdisciplinary team was conducted to review the incident and implement systemic improvements. The facility's medical director assessed all 56 residents who could have been affected during the outage period and reported no adverse effects were identified.
Ongoing Oversight and Monitoring
The immediate jeopardy citation requires ongoing monitoring by state survey agencies to ensure sustained compliance with medication administration requirements. The facility must demonstrate consistent adherence to corrected policies and procedures during follow-up inspections.
The incident highlights the critical importance of emergency preparedness in long-term care facilities, particularly regarding medication administration systems. Technology failures cannot become barriers to essential patient care, and facilities must maintain robust backup systems and staff training to ensure resident safety during unexpected disruptions.
Knollwood Healthcare serves 56 residents and is located at 3151-A Knollwood Drive in Mobile, Alabama. The facility remains under enhanced regulatory oversight following the immediate jeopardy citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Knollwood Healthcare from 2025-03-27 including all violations, facility responses, and corrective action plans.
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