The medication error occurred at The Cove of Cascadia on November 20, when RN #2 prepared to give Resident #9 their prescribed insulin injection. The resident's blood glucose reading was 233 — well above normal levels.
Federal inspectors observed the nurse remove a Novolog insulin pen from the medication cart and dial it to 17 units total: 15 units as the standard prescribed dose, plus 2 additional units according to the facility's sliding scale for elevated blood sugar.
But the nurse skipped a critical safety step.
RN #2 failed to prime the insulin pen with 2 units before dialing the ordered dose. This priming process ensures the pen delivers accurate medication amounts by clearing air bubbles and verifying proper flow.
The nurse administered the insulin to Resident #9 at 11:35 AM without realizing the error.
When questioned ten minutes later, RN #2 admitted to inspectors that he had not primed the insulin pen. He said he was unaware this step was necessary before giving insulin injections.
The next morning, the facility's chief nursing officer confirmed that insulin pens should indeed be primed with 2 units prior to administering any ordered dosage.
Resident #9 has multiple serious health conditions including diabetes and heart failure. The resident was initially admitted to the facility earlier this year and readmitted recently with ongoing medical needs requiring careful monitoring.
The resident's physician had ordered Novolog insulin injections three times daily for Type 2 diabetes, along with additional sliding scale doses based on blood glucose readings. For blood sugar between 200-249, like Resident #9's reading of 233, facility protocol called for 2 extra units.
Unprimed insulin pens can deliver unpredictable doses. Air bubbles or mechanical issues may cause residents to receive too little medication, leaving their blood sugar dangerously high. In some cases, the pen may compensate by delivering too much insulin during subsequent injections, potentially causing severe low blood sugar episodes.
For diabetic residents with multiple health conditions like heart failure, unstable blood glucose levels pose serious risks including cardiovascular complications, kidney damage, and life-threatening diabetic emergencies.
The inspection occurred following a complaint about care at the facility. Federal investigators found the medication error placed Resident #9 at risk for not receiving the prescribed insulin dosage and experiencing other adverse health outcomes.
Insulin pen priming is a fundamental safety requirement taught in basic nursing education. The procedure takes seconds but ensures each injection delivers the precise medication amount ordered by physicians.
The facility's own nursing leadership acknowledged the requirement, yet the error occurred during routine medication administration under normal operating conditions.
Resident #9 continues to require multiple daily insulin injections to manage their diabetes alongside treatment for heart failure and other medical conditions. The resident's care plan depends on precise medication dosing to prevent dangerous fluctuations in blood glucose levels.
The nursing home received a citation for failing to ensure residents remain free from significant medication errors. Federal regulators classified the violation as causing minimal harm or potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cove of Cascadia, The from 2025-11-21 including all violations, facility responses, and corrective action plans.