The incident at Ambrosio Guillen Texas State Veterans Home went unreported to administrators for more than a month, despite a nursing assistant witnessing the unsafe injection technique and reporting it to weekend supervisors.
Restorative nursing assistant B told state inspectors she saw RN C "passing by the resident and did not tell the resident he was going to give him an insulin injection and just poked the resident with the needle through his shirt." The veteran "was startled when RN C had done this to him."
The assistant said she immediately reported the incident to RN supervisor G, the weekend supervisor on duty. But when inspectors interviewed the Director of Nursing on September 9, she said she "was not aware" that the unsafe injection had been reported.
"The RN Supervisor G should have reported this to me or to RN ADON E and LVN Unit Manager F right away, to immediately address this concern to prevent it from reoccurring," the Director of Nursing told inspectors. "This practice could place the resident at risk of infection."
RN C later admitted to inspectors that he violated protocols he learned in nursing school. He acknowledged that "the injection site needs to be cleaned prior to administering the injections" and that he "was also trained in nursing school not to administer insulin through the clothes."
"He said, this could place the resident at risk for infection," according to the inspection report.
The nurse also told investigators that RN supervisor G and LVN unit manager F had called him after the incident to inform him "that insulins could not be administered in the dining room" and that "he had not followed the technique on insulin administration like he was trained to do in nursing school."
The nursing assistant who witnessed the injection told inspectors she didn't think "what RN C did to the resident was right, because he had not cleaned the area on the arm prior to injecting the insulin to the resident, and that placed the resident at risk for infection."
She said the incident happened "more than a month ago on the weekend" and she could not remember which resident received the improper injection. When she followed up with RN supervisor G about her concerns, "all she said was that she had reported this to the DON."
But that report apparently never reached the Director of Nursing.
When inspectors examined the facility's training and oversight procedures, they discovered the veterans home had no skills checklist for insulin administration. The Director of Nursing told inspectors on September 12 that "the facility did not have a Skills Checklist on Insulin Administration for the licensed staff."
She said she had located a skills checklist in one of the facility's manuals that documented proper injection technique: "select an appropriate injection site, free from edema, induration, tenderness, or skin irritation. Cleanse site with alcohol swab beginning at center of site and rotating outward approximately 2 inches. Allow skin to dry completely; do not fan or blow on site."
The checklist also required staff to inform residents before injecting, telling them "he/she will feel a slight pinch, pressure, or stinging sensation as the insulin is injected."
"This will ensure licensed staff do not inject insulin over the clothes without cleaning the injection site, prior to administering the insulin," the Director of Nursing told inspectors.
She said she was still searching for a policy on insulin administration and would provide inspectors with a copy if she found one.
Inspectors requested copies of nursing policies on injection administration and pharmacy policies on injection administration. The Director of Nursing failed to provide either document before the inspection concluded.
The facility's medication administration policy, revised July 1, 2025, states only that staff should "administer medications as ordered in accordance with manufacturer specifications."
According to manufacturer specifications for insulin that inspectors obtained online, subcutaneous insulin injections should be administered "into the abdominal area, thigh, buttocks or upper arm" within 5-10 minutes before a meal.
The specifications make no mention of injecting through clothing or skipping skin preparation.
The improper injection technique violated multiple safety protocols designed to prevent infections in vulnerable residents. Injecting through clothing can introduce bacteria and other contaminants into the injection site, while failing to clean the skin with alcohol eliminates a basic barrier against infection.
The incident also violated residents' right to be informed about their medical care and to have procedures performed with dignity rather than being startled by unexpected injections while eating in a public dining room.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ambrosio Guillen Texas State Veterans Home from 2025-09-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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