Greenfield Rehab And Nursing Center

F 0760 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

her preceptor, RN ‘D', called 911, assessed Resident R801, and rechecked the resident's blood sugar. When queried about whether she rechecked the order after she filled the whole syringe with insulin to ensure the proper dose, RN ‘C' said she did but compared it with the strength again. RN ‘C' reported she did not have a lot of experience administering insulin, that it was her first bedside nursing job and she never worked in a long-term care facility previously. RN ‘C' reported she received three days of orientation where she shadowed another nurse and asked for a couple extra days before being assigned on her own. RN ‘C' further reported when she drew up Resident R801's insulin, she thought it was a lot, but because another resident on that same set was prescribed a very high dose of insulin she thought it was correct. RN ‘C' did not seek out clarification and verified the dose, but read the incorrect part of the order. On 10/7/25 at 9:36 AM, an

interview was conducted with RN ‘D' via the telephone. When queried about what happened with Resident R801's insulin on 9/28/25, RN ‘D' reported RN ‘C' came to her and said she thought she had a medication error.

When queried about the error, RN ‘D' reported RN ‘C' thought she gave 100 units of insulin to Resident R801 instead of 3 units. RN ‘D' reported Resident R801 was assessed and blood sugar was rechecked. At that time, Resident R801's blood sugar remained at baseline. RN ‘D' reported RN ‘C' called the physician and sent Resident R801 out 911. A review of

an Incident Report dated 9/28/25 at 5:00 PM, completed by RN ‘C', revealed a statement by RN ‘C' taken

on 10/1/25 that noted, .I took the pt (patient's) blood 124. I read the order thinking the medication strength was the dose to be given, 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. I immediately notified (RN ‘D') who had been my preceptor and called 911 while (RN ‘D') assessed the resident. I then retook the residents blood sugar while (RN ‘D') notified the DON (Director of Nursing). EMS (Emergency Medical Services) arrived, I called the Provider oncall and notified them patient was being transferred due to being given 100 units of insulin.On 10/7/25 at approximately 12:45 PM, an interview was conducted with the DON. When queried about the medication error made by RN ‘C', the DON reported RN ‘C' should have confirmed the insulin dose when she noticed she filled up the whole syringe. A review of Resident R801's hospital records revealed the following: An ED (Emergency Department) Provider Note dated 9/28/25 revealed the following documentation, .5:26 PM.Patient.may have received excessive insulin in error at nursing facility. Per EMS she accidentally received 100 units lispro instead of 3 units. Her initial blood glucose on arrival to out emergency department was 103, but she did receive some oral glucose prior to arrival.6:16 PM Repeat POC (point-of-care) glucose 48 (low). D50 (Dextrose 50%) given with improvement to 185. Will admit for serial blood sugar checks and management.8:20 PM MICU (Medical Intensive Care Unit) evaluated patient, and they will admit her to the MICU admission at this time.

Switched dextrose gtt (glucose tolerance test) to D10 (Dextrose 10%) and solu-cortef (steroid medication) given.A review of a facility policy titled, Medication Administration, dated 8/7/23, revealed, in part, the following, .Medications are administered in accordance with the following rights of medication administration.Right dose.

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