BRIA of Godfrey: Double Insulin Dose Sent Resident to ER - IL
The incident at BRIA of Godfrey came to light through a complaint inspection completed October 15, 2025. Federal inspectors cited the facility for medication administration failures, finding that the mix-up sent the resident, identified in inspection records only as R2, to a local hospital with elevated blood pressure.
R2's family member, identified as V14, said the facility called him to report that his relative had received a double dose of insulin. He was told there had been a mix-up over which nurse was responsible for which resident. He was also told R2 was being taken to the hospital, not for the insulin error itself, but for high blood pressure. V14 told inspectors that R2 can become anxious and does not always understand what is going on around her.
The nurse who administered the first dose, identified as V9, an LPN, described the sequence of events to inspectors the following afternoon. She said she had gone to R2's room to perform a blood sugar check and administer bedtime medications, including R2's Lantus, a long-acting insulin. After giving the injection, she tried to document it in the medication administration record, the electronic log nurses use to track what each resident has received and when. The facility's internet was down. She could not click the confirmation.
About an hour later, a second nurse, identified as V10, gave R2 another dose of the same insulin. V10 believed R2 was her resident to medicate. Because V9 had been unable to log the first dose, there was no electronic record to stop V10.
V9 told inspectors that the facility has frequent internet and computer problems.
That detail sits at the center of what inspectors found. The facility's own medication policy, last reviewed in April 2025, instructs nurses to check the medication administration record before giving any drug, confirming the right medication, dose, route, patient, and time. The policy existed. The computer system that makes it possible to follow that policy did not reliably work.
When a nurse cannot record a medication because the internet is down, the safeguard disappears. The next nurse who opens the chart, or cannot open it, has no way of knowing what already happened. At BRIA of Godfrey, that gap lasted about an hour, and it was enough.
Lantus is not a medication with a narrow margin for error. A double dose of long-acting insulin can drive blood sugar dangerously low, a condition that can cause confusion, loss of consciousness, and, in severe cases, death. The inspection report classified the harm level as minimal harm or potential for actual harm, and noted that few residents were affected. R2 was evaluated at the hospital and the report does not describe lasting injury.
But the circumstances that produced the error, two nurses uncertain about patient assignments and a computer system too unreliable to catch the mistake, were not described in the inspection report as resolved.
V14 said his family member was sent to the hospital for high blood pressure. He said she can get anxious. He said she does not always understand what is going on. What she understood about the night she received two insulin injections, or what anyone told her about it, the report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bria of Godfrey from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
BRIA OF GODFREY in GODFREY, IL was cited for violations during a health inspection on October 15, 2025.
The incident at BRIA of Godfrey came to light through a complaint inspection completed October 15, 2025.
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.