The nurse administered 16 units of Novolog insulin to Resident 86 on September 9 without first priming the FlexPen device. Priming removes air bubbles and ensures the prescribed dose reaches the patient rather than remaining trapped in the pen's mechanism.
Resident 86 has diabetes and cognitive communication deficits. The resident's physician had ordered 14 units of Novolog with meals, plus additional sliding-scale doses based on blood sugar readings. When the resident's blood sugar measured 173 that morning, the nurse correctly calculated the total dose at 16 units — 14 for the meal plus 2 additional units per the sliding scale.
But the nurse dialed the FlexPen to 16 units and injected the insulin into the back of the resident's left arm without the required priming step.
The facility's own nursing leadership confirmed the safety protocol was mandatory. Assistant Director of Nursing and the Nurse Manager told inspectors on September 12 that insulin FlexPens "are expected to be primed by the nursing staff administering the medication with 2 units of insulin each time the FlexPen is being used."
Registered Nurse A explained the medical rationale during a September 11 interview: "Priming the pen removes any air bubbles and ensures the insulin dose more accurate."
The Administrator agreed, telling inspectors she "would expect staff to prime insulin FlexPens prior to each use."
Yet confusion about the policy existed among nursing staff. Licensed Practical Nurse K told inspectors that insulin FlexPens "should only be primed when the pen is being used for the first time." When pressed, LPN K admitted uncertainty about whether pens required priming with each use.
This knowledge gap represented a significant safety concern for diabetic residents who depend on precise insulin dosing. Too little insulin can lead to dangerously high blood sugar levels, while too much can cause life-threatening hypoglycemia.
The inspection occurred in response to a complaint, though the specific nature of the complaint was not detailed in the report. Inspectors classified the violation as having minimal harm or potential for actual harm, affecting some residents.
The facility's medication administration policy expects staff to "follow physician orders and accurately give residents their medications in their entirety." The failure to prime insulin pens directly contradicted this standard, potentially compromising the accuracy of every insulin injection administered by staff who skipped the priming step.
FlexPen devices are commonly used in nursing homes because they're easier to handle than traditional vials and syringes. However, they require specific techniques to function properly. Air bubbles can form in the pen's cartridge, particularly after storage or transport. Without priming, these bubbles can prevent the full prescribed dose from being delivered to the patient.
For diabetic residents like Resident 86, who require both mealtime and sliding-scale insulin coverage, dosing accuracy becomes even more critical. The resident's complex regimen demanded precise administration — 14 units with meals, then additional units ranging from 2 to 10 depending on blood sugar levels.
The September 9 observation revealed a breakdown in this precision. Despite correctly calculating the 16-unit dose based on the resident's blood sugar reading of 173, the nurse's failure to prime the pen meant the resident may not have received the full prescribed amount.
The medication error occurred during the morning shift, when many residents receive their most complex medication regimens. Insulin administration typically peaks during this time as residents prepare for breakfast and require both long-acting and rapid-acting insulin coverage.
Staff interviews revealed inconsistent understanding of basic insulin administration protocols. While nursing leadership clearly articulated the priming requirement, floor nurses demonstrated varying levels of knowledge about proper FlexPen technique.
This knowledge gap extended beyond a single nurse. The fact that LPN K expressed uncertainty about priming requirements suggested the facility's training and oversight systems had failed to ensure consistent medication administration practices among nursing staff.
The violation highlighted broader concerns about medication safety protocols at the 11-bed facility. When nursing staff lack clear understanding of basic medication administration techniques, residents face increased risks of adverse drug events and therapeutic failures.
Resident 86's case illustrated these risks in concrete terms. A diabetic resident with cognitive deficits cannot advocate for proper medication administration or recognize when doses may be inaccurate. The resident depends entirely on nursing staff competence and adherence to safety protocols.
The facility now faces questions about its medication training programs and quality assurance measures. The Administrator's acknowledgment that staff should prime insulin pens "prior to each use" contrasted sharply with the observed practice and staff confusion about requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Big Bend Woods Healthcare Center from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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