Resident 14's blood glucose level reached 528 by the time testing resumed on October 22, 2025. The facility's nurse practitioner called the resident "a very fragile diabetic" and said missing the checks and insulin doses "could have easily caused Resident 14 significant harm."
The crisis began the morning of October 21 when staff discovered they had no glucose monitoring strips left. The resident was scheduled for four daily blood sugar checks and multiple insulin injections based on those readings.
Instead of the required monitoring, staff marked "NA" — not applicable — on the medication administration record for four consecutive scheduled blood glucose checks. They also marked "NA" for three insulin doses the resident should have received during that period.
The facility's Director of Nursing confirmed that staff had no backup supply of test strips in the building. When the expected shipment failed to arrive October 21, administrators made no attempt to obtain strips elsewhere, even though the resident required round-the-clock diabetes management.
The nurse practitioner was in the facility around 11:30 AM on October 21 and overheard staff discussing the shortage. Staff told the practitioner they had ordered replacement strips and expected delivery later that day. If the strips didn't arrive by suppertime, they said, the facility would go to the pharmacy to purchase some.
That didn't happen.
When the nurse practitioner returned October 22, staff informed them that no strips had been obtained. Resident 14 had gone without blood glucose monitoring since the previous morning and had missed all scheduled insulin doses.
The facility's own pharmacy had no strips available. The Director of Nursing admitted that staff "did not attempt any other method of obtaining strips."
Resident 14's medication orders detailed the complexity of their diabetes management. They received Tresiba insulin once daily, plus sliding-scale insulin twice daily based on blood sugar readings. The sliding scale called for 3 units of insulin when blood glucose reached 176-200, escalating to 12 units at 401-402 with instructions to call the provider.
The orders also required staff to monitor blood glucose four times daily and notify the provider if readings dropped below 80 or exceeded 400, or if the resident showed symptoms.
None of this monitoring occurred during the shortage.
Replacement strips finally arrived before lunch on October 22. Staff immediately tested Resident 14's blood sugar and found it had spiked to 528 — well above the 400 threshold requiring provider notification.
The nurse practitioner had to order an additional insulin dose to bring down the dangerously high level.
Federal inspectors found no progress notes documenting that staff had notified the provider about the missed blood glucose checks or insulin doses. The facility's own medication administration records showed the gap in care with "X" marks for the missed evening doses on October 21 and morning dose on October 22.
The nurse practitioner's account revealed the facility had advance warning. Staff knew about the shortage by mid-morning October 21 and told the practitioner they had a plan to obtain replacement strips if needed.
They never executed that plan.
For a resident described as "very fragile" diabetic, the consequences of the oversight extended far beyond missed medication doses. The blood sugar reading of 528 represented a medical emergency — normal levels typically range between 70-140.
The Director of Nursing's admission that the facility made no effort to find alternative sources for the strips highlighted the breakdown in basic care protocols. Pharmacies, medical supply stores, and other healthcare facilities routinely stock glucose monitoring supplies.
The inspection found the facility violated federal requirements for medication administration and diabetes management. The violation was classified as causing minimal harm with potential for actual harm to few residents.
Resident 14's case illustrates how supply chain failures can cascade into medical emergencies when facilities lack adequate backup plans for essential medical supplies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Skyview Care and Rehab At Bridgeport from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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