Sublette County Health: Medication Error Harm - WY
The medication error occurred July 18 at Sublette County Health when RN #1 used a tuberculin syringe instead of an insulin syringe because she couldn't find any insulin syringes, according to federal inspection records.
The resident had severe cognitive impairment with a mental status score of 3 out of 15 and multiple serious conditions including heart failure, atrial fibrillation, kidney problems and insulin-dependent diabetes.
Physician orders from July 10 specified the resident should receive 8 units of sliding scale insulin for blood sugars between 351-400 mg/dl. On July 18, the resident's blood sugar measured 377 mg/dl before insulin administration.
But the nurse delivered ten times the prescribed dose.
Within hours, the resident exhibited classic signs of severe hypoglycemia. The nursing report documented the resident "was not acting like him/herself and exhibited diaphoresis, cool skin, rapid breathing, and changes in level of consciousness."
The resident was transferred to an acute care hospital that evening. Hospital records show admission to the intensive care unit for management of hypoglycemia and hypotension following the accidental insulin overdose.
During the August 19 federal inspection, RN #1 confirmed she administered 80 units instead of 8 units at approximately 4:30 PM on July 18. She revealed that during insulin administration, she used a tuberculin syringe instead of an insulin syringe because she couldn't locate proper insulin syringes.
The director of nursing confirmed the wrong insulin dose resulted from the nurse using the wrong type of syringe.
Tuberculin syringes measure in different increments than insulin syringes, creating potential for dramatic dosing errors when used interchangeably. The confusion between syringe types turned what should have been a routine diabetes management into a life-threatening medical emergency.
The facility's own incident report, filed July 18, documented the medication error involving sliding scale insulin administration. A supplemental statement filed the following day detailed the resident's deteriorating condition and emergency transfer.
Federal inspectors determined the insulin overdose constituted actual harm to the resident. The violation occurred despite facility policies designed to prevent significant medication errors.
The inspection found Sublette County Health failed to ensure residents remained free from significant medication errors. The finding specifically cited the facility's failure to protect one resident from harm, though inspectors reviewed seven residents total during the complaint investigation.
The resident's complex medical history made the insulin error particularly dangerous. Beyond diabetes, the resident struggled with heart failure and kidney problems that could complicate treatment of severe hypoglycemia.
Hospital physicians documented the seriousness of the overdose in their admission notes, emphasizing the need for intensive monitoring following the accidental tenfold insulin administration.
The nursing shortage of proper insulin syringes created the conditions for error, but the nurse's decision to substitute a tuberculin syringe without adjusting for measurement differences caused the overdose.
Federal regulations require nursing homes to maintain medication administration systems that prevent significant errors. The inspection determined Sublette County Health's systems failed when basic supplies weren't available and staff improvised with dangerous alternatives.
The July incident highlights how equipment shortages can cascade into patient harm when nurses make substitutions without accounting for critical differences in medical devices.
The resident's transfer to intensive care represents the most serious consequence documented in the inspection report. Hospital records confirm the severity of hypoglycemia and blood pressure problems requiring specialized medical intervention.
RN #1's admission during the federal interview confirmed both the dosing error and the underlying cause. Her inability to locate insulin syringes led to the tuberculin syringe substitution that multiplied the insulin dose tenfold.
The facility investigation, completed after the incident, documented the sequence of events but couldn't undo the resident's hospitalization and intensive care stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sublette County Health from 2025-08-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Sublette County Health in Pinedale, WY was cited for violations during a health inspection on August 19, 2025.
Physician orders from July 10 specified the resident should receive 8 units of sliding scale insulin for blood sugars between 351-400 mg/dl.
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.