Licensed Practical Nurse #721 skipped priming the insulin pen entirely before injecting Resident #138 on September 23. When an inspector asked her about it 42 minutes later, she said she didn't need to prime the pen.
She was wrong.
Federal inspectors found Greenbrier Health Center's medication error rate hit 6.7 percent during their October visit, exceeding the maximum allowed 5 percent threshold. Two of five residents observed during medication administration received improper insulin injections from nurses who misunderstood basic safety protocols.
The consequences of insulin administration errors extend beyond simple medication mistakes. Without proper priming, patients may receive air instead of their prescribed diabetes medication, leading to dangerous underdosing that can trigger life-threatening blood sugar spikes.
Resident #138 had been living at the 123-bed facility since May, managing diabetes with diabetic chronic kidney disease. Her care plan specifically required insulin injections per medical provider orders. She was cognitively intact and relied on nursing staff to properly administer her daily insulin Lispro injections.
The physician had ordered four units of insulin with meals to control her blood sugar. But when LPN #721 removed the insulin pen from the medication cart that September morning, she attached the needle, dialed the dose, and injected without the critical priming step.
Insulin pen manufacturers require priming before every injection to ensure accurate dosing. The process involves dialing two units, tapping to remove air bubbles, pressing the dose knob, and watching for a drop or stream of insulin at the needle tip. If no insulin appears, the process must be repeated until medication flows properly.
The instructions are explicit: "Without priming, you may inject air instead of insulin leading to an underdose."
A different nurse made the opposite error with Resident #87, a cognitively intact patient admitted in July with type two diabetes and hyperglycemia. LPN #800 primed the Glargine Solostar pen injector on September 24, but she did it at the wrong time.
She primed before attaching the needle, then put the needle on and dialed 34 units for the morning injection. The priming should happen after needle attachment to ensure the medication pathway is clear and ready for injection.
LPN #800 confirmed to inspectors that she primed before putting the needle on, not after. Like her colleague, she worked throughout the facility, potentially carrying these incorrect techniques to other diabetic residents.
Both residents depended entirely on nursing staff for proper insulin administration. Their care plans specifically called for insulin injections as ordered by physicians. Both had been managing diabetes for months at the facility.
The manufacturer's instructions, revised as recently as July 2023, leave no ambiguity about the priming requirement. The step-by-step process is designed to prevent exactly what inspectors observed: nurses injecting air or delivering incorrect doses to vulnerable diabetic patients.
Resident #87's morning insulin dose of 34 units represents a significant amount of medication. An underdose caused by improper administration could leave him with dangerously elevated blood sugar levels throughout the day.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm. But diabetes management requires precision. Blood sugar fluctuations can trigger complications ranging from diabetic ketoacidosis to coma in severe cases.
The facility's medication error rate calculation included these insulin administration failures among other medication mistakes observed during the inspection. At 6.7 percent, the error rate exceeded federal standards designed to protect nursing home residents from preventable medication harm.
Both nurses told inspectors they worked in all areas of the facility, suggesting the insulin administration errors weren't isolated to specific units or shifts. The systemic nature of the problem indicates training deficiencies that could affect other diabetic residents throughout Greenbrier Health Center.
The inspection occurred in response to a complaint, suggesting someone had already raised concerns about medication administration at the facility. The insulin errors inspectors documented validated those concerns with specific examples of nurses failing to follow basic safety protocols.
Resident #138 continues to require daily insulin injections to manage her diabetes and chronic kidney disease. Resident #87 still needs his morning insulin dose to control his type two diabetes and hyperglycemia. Both remain dependent on nursing staff who, as of the October inspection, were still administering insulin incorrectly.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenbrier Health Center from 2025-10-08 including all violations, facility responses, and corrective action plans.