COLVILLE, WA - A diabetic resident at Prestige Care & Rehabilitation - Pinewood Terrace experienced multiple life-threatening episodes of extremely low blood sugar after receiving an insulin injection that was 7.2 times their prescribed dose, according to a May 2025 federal inspection report.
Medication Mix-Up Results in Dangerous Overdose
The medication error occurred on May 13, 2025, when a newly licensed practical nurse administered 72 units of Lantus insulin intended for another resident to Resident 34, who was only prescribed 10 units. The Institute for Safe Medication Practices classifies insulin as a "high alert medication" because errors can cause devastating consequences for residents.
Resident 34, who has diabetes and end-stage kidney disease requiring dialysis, immediately told staff something was wrong. During an interview, the resident pointed to orange juice on their breakfast tray and explained they were "given orange juice because they were given too much insulin that morning."
The massive insulin overdose triggered an extended period of symptomatic hypoglycemia that required rescue medications on five separate occasions over approximately 48 hours.
Critical Blood Sugar Episodes and Emergency Interventions
Following the overdose, Resident 34's blood sugar levels became dangerously unstable. Medical records document a series of critical events:
May 14, 2025 - First Crisis: At 6:11 AM, the resident's blood sugar dropped to 64 mg/dl, requiring the first glucagon rescue injection. Normal blood sugar levels range from 70-140 mg/dl.
At Dialysis Center: During dialysis treatment, the resident's blood sugar plummeted to 50 mg/dl, then critically low to 38 mg/dl. Dialysis staff administered glucagon gel twice. Upon return to the facility, the resident's blood sugar was 48 mg/dl. Staff documented the resident appeared "pale and sweating" and administered another glucagon injection plus sugar packets.
May 15, 2025 - Most Severe Episode: At 4:40 AM, nursing staff found Resident 34 with "abnormal behavior," mumbling words, sweating, and lethargic with minimal response. Blood sugar had dropped to a critical 36 mg/dl, requiring another glucagon injection.
The resident described the experience during interviews: "When their blood sugar dropped down so low, they felt like they were going to die" and were "afraid to go to sleep the night prior because they thought if they did, they were going to die."
Medication Administration Failures
The error occurred during medication preparation for multiple residents. Staff P, a recently licensed practical nurse in orientation, was working with Staff L, a registered nurse. The investigation revealed that Staff L prepared insulin for Resident 42 (72 units) and handed it to Staff P, but failed to accompany the new nurse to ensure proper resident identification.
Staff P became confused and administered the high-dose insulin to Resident 34 instead. The facility's investigation noted that residents did not wear identification bracelets, making proper identification more challenging.
Additional Medication Safety Violations
The inspection also identified medication errors affecting Resident 61, who did not receive prescribed doses of critical medications:
Blood Thinner Missed: Resident 61 did not receive Xarelto, an anticoagulant prescribed for atrial fibrillation. The medication was marked "not available" despite being stocked in the facility's emergency medication supply.
Diabetes Medication Delays: The resident missed three consecutive weekly doses of Ozempic, an injectable diabetes and weight management medication, between April 25 and May 9, 2025.
Medical Significance and Risks
Severe hypoglycemia can cause brain damage, seizures, coma, and death. The multiple episodes requiring rescue medications demonstrated the severity of the overdose. Blood sugar levels in the 30s are considered medical emergencies requiring immediate intervention.
Missing anticoagulant doses places residents with atrial fibrillation at increased risk for stroke and blood clots. Skipping diabetes medications can lead to poor blood sugar control and cardiovascular complications.
Staff Training and Oversight Deficiencies
The inspection revealed significant gaps in medication safety protocols:
- Staff P had not received a medication competency checklist until after the error occurred - No systematic verification process ensured proper resident identification - Emergency medications were not properly documented on medication administration records - The medical provider was not notified when the resident required five rescue interventions
Staff P stated their orientation consisted mainly of "filling out paperwork, instructions on how to don and doff personal protective equipment and hand hygiene" rather than comprehensive medication administration training.
Facility Response and Provider Concerns
The facility's medical provider expressed serious concerns about the incident management. During an interview, the nurse practitioner stated they were not notified about the multiple rescue medication administrations and agreed the resident "might need to be hospitalized to stabilize their blood sugar."
The provider emphasized that "waiting until a resident was unconscious before sending them to the emergency room was too late" and expected notification when residents experience blood sugar levels in the 30s.
Medication Safety Standards
Federal regulations require nursing homes to ensure medications are administered as prescribed and that residents are free from significant medication errors. The facility's failure to implement proper identification procedures, provide adequate training, and monitor high-risk medications violated these standards.
Industry best practices for insulin administration include double-checking calculations, verifying patient identity, and having protocols for managing high-alert medications. The errors at Prestige Care & Rehabilitation - Pinewood Terrace demonstrate the critical importance of these safety measures.
This incident highlights the potentially life-threatening consequences of medication errors in nursing home settings and the need for robust safety protocols to protect vulnerable residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prestige Care & Rehabilitation - Pinewood Terrace from 2025-05-23 including all violations, facility responses, and corrective action plans.
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