The resident, identified as Resident #17, received insulin injections seven days a week but staff failed to check blood glucose levels on multiple occasions in September, according to a federal inspection completed October 3. On September 30, the resident was taken to a doctor's appointment and never returned to the facility, instead being admitted to the hospital that night for hypoglycemia and hypotension.
Federal inspectors found a pattern of missed blood glucose checks throughout September. On September 16, 25, 26 and 27, staff documented no blood glucose levels at the 7:30 a.m. medication time. On September 20 and 22, no glucose levels were recorded at 11:00 a.m. On September 25, the 4:00 p.m. check was also missing.
The resident's physician had ordered three different types of insulin. A long-acting insulin called Degludec was to be injected at 22 units each afternoon. Fast-acting Lispro insulin was ordered at 5 units before each meal. A sliding scale protocol required additional Lispro doses based on blood glucose readings: 2 units for levels between 200-250, 4 units for 251-300, 6 units for 301-350, and 8 units for 351-400.
But the doctor's orders contained a critical gap. There were no instructions for when to notify the physician about dangerous glucose levels.
During the inspection, nursing staff revealed they were operating without clear protocols. Licensed Practical Nurse D told inspectors she would contact a physician for blood glucose levels of 60 or below, or above 400. Licensed Practical Nurse G said she would call for levels below 60 or above 450.
The confusion extended beyond individual judgment calls. When asked what to do about sliding scale insulin orders that lacked physician notification parameters, LPN G said she would contact the doctor to request specific instructions.
The facility's Director of Nursing acknowledged the problem had been festering for weeks. She told inspectors she had identified issues in September with staff failing to notify physicians when blood glucose levels exceeded safe ranges, inconsistently documenting glucose readings, and recording "NA" and "NI" entries without explanation in progress notes.
The DON provided training records from September 19 and 22 showing staff had received instruction on blood sugar protocols, insulin administration, and requirements for documenting physician notifications when glucose levels fell outside normal ranges. The training emphasized the need for detailed progress notes when glucose readings were problematic.
Despite the training, the problems persisted. The resident's medical records showed a troubling pattern of missing documentation right up until the hospitalization.
On September 30, progress notes tracked the resident's deteriorating condition throughout the day. At 1:21 p.m., staff noted the resident was on leave for a physician follow-up appointment. At 5:24 p.m., the resident remained at the doctor's office. By 11:31 p.m., the charge nurse received notification that the resident had been admitted to the hospital.
The resident's quarterly assessment from earlier that month had described someone who was cognitively intact with diagnoses of high blood pressure and diabetes. The care plan, updated September 23, set a goal of preventing diabetes-related complications through proper medication administration and monitoring for side effects and effectiveness.
The DON expressed frustration during her interview with inspectors. She said she expected staff to follow physician orders and notify doctors when blood glucose levels exceeded ordered parameters. When sliding scale orders lacked notification instructions, she expected staff to either follow facility policy or contact the physician directly for guidance.
"When nurses contact the physicians, they should document it in the progress notes," she told inspectors. "When nurses document NA or NI, there should be an explanation documented in the progress notes. She does not know why this is not being done."
The inspection found that staff were administering powerful diabetes medications without the safety net of consistent monitoring. Insulin injections can cause blood sugar to drop to life-threatening levels, particularly when given without proper glucose checks to guide dosing decisions.
The resident's hospitalization for hypoglycemia and hypotension represented exactly the kind of diabetes-related complication the care plan was designed to prevent. Federal inspectors classified the violation as having caused minimal harm or potential for actual harm to some residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Sophia Health & Rehabilitation Center from 2025-10-03 including all violations, facility responses, and corrective action plans.
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