Greenfield Rehab: Insulin Overdose Sent Resident to ICU - MI
The resident, identified in inspection records as R801, was transferred by ambulance to a hospital emergency department on September 28, 2025. Her blood sugar was holding at 103 when she arrived. By 6:16 that evening it had dropped to 48. Staff gave her dextrose. By 8:20 p.m., the medical intensive care unit had been called and she was admitted.
The nurse who gave the injection, identified as RN C, wrote in her incident report that she had drawn R801's blood sugar, read it at 124, and then misread the medication order. She thought the insulin's listed strength — 100 units per milliliter — was the dose itself. She filled the syringe completely and injected it into R801's left arm. It was only when she went to chart the administration that she realized what she had done.
"I read the order thinking the medication strength was the dose to be given," RN C wrote in a statement taken October 1. "I drew up 100 units in the insulin syringe instead of the 3 units ordered. I administered the insulin in her left arm. I went to chart administration was complete and realized I had made a medication error."
RN C told inspectors she had noticed something was off before she gave the injection. She knew the syringe was full. She thought it was a lot. But there was another resident on the same medication pass who was prescribed a very high insulin dose, and RN C reasoned that maybe this was just one of those cases. She did not stop. She did not ask.
She also told inspectors she did not have much experience with insulin. It was her first bedside nursing job. She had never worked in a long-term care facility before. She said she received three days of orientation, shadowing another nurse, and that she had asked for a few extra days before being assigned to work on her own.
RN D, who had been RN C's preceptor, told inspectors by phone on October 7 that RN C came to her after the injection and said she thought she had made a medication error. RN D assessed R801 and rechecked her blood sugar, which at that point was still at baseline. RN C called the on-call physician. RN D notified the Director of Nursing. EMS arrived and R801 was transferred.
The emergency department note from that evening documented what came next. The patient arrived with a blood glucose of 103 after receiving some oral glucose before the ambulance got there. Forty-five minutes later it had fallen to 48. Staff administered Dextrose 50% intravenously, and her glucose climbed to 185. But the correction didn't hold. The MICU team evaluated her and admitted her, switching her to a continuous Dextrose 10% drip and giving her a steroid medication to help stabilize her blood sugar over time.
The Director of Nursing, interviewed by inspectors on the afternoon of October 7, said RN C should have confirmed the dose when she noticed she had filled the whole syringe.
That was the extent of what the inspection report captured from the Director of Nursing on the subject.
Federal inspectors cited the facility for causing actual harm to a resident through a medication error, the citation carrying a finding that the failure was not merely a risk but had produced a concrete injury. R801 spent the night in intensive care, on an IV drip, under serial blood sugar monitoring, because a nurse misread milligrams for micrograms, strength for dose, and then pushed forward when her own instinct told her the amount was wrong.
The inspection was conducted as a complaint investigation. The report does not say who filed the complaint or what has changed at the facility since.
R801's name does not appear in the inspection record. What does appear is her blood sugar reading at 6:16 p.m., sitting at 48, in an emergency department she reached by ambulance from a nursing home where she had been in someone's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenfield Rehab and Nursing Center from 2025-10-07 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 26, 2026 · Our methodology
Greenfield Rehab and Nursing Center in Royal Oak, MI was cited for violations during a health inspection on October 7, 2025.
The resident, identified in inspection records as R801, was transferred by ambulance to a hospital emergency department on September 28, 2025.
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.