Sublette County Health
Inspection Findings
F-Tag F0760
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, incident report review, and facility investigation review, the facility failed to ensure resident's were free from significant medication errors for 1 of 7 sampled residents (#1) reviewed. This failure resulted in harm to resident #1 who was hospitalized following an insulin overdose.
The findings were: 1. Review of the admission Minimum Data Set assessment dated [DATE REDACTED] showed resident #1 had a brief interview for mental status score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which include heart failure, atrial fibrillation, renal insufficiency and diabetes mellitus. Further review showed the resident was insulin dependent for diabetes mellitus. The following concerns were identified: a. Review of the facility incident report dated 7/18/25 showed a potential medication error for resident #1 involving sliding scale insulin administration. b. Review of physician orders dated 7/10/2025 for sliding scale insulin showed the resident was to receive 8 units of insulin for blood sugars ranging from 351-400 mg/dl (milligrams per deciliter). c. Review of the resident's medication administration record dated 7/18/25 showed the residents blood sugar was 377 mg/dl prior to insulin administration.d. Review of the Mediation Error Report dated 7/18/25 showed registered nurse (RN) #1 administered 80 units of insulin instead of 8 units on 7/18/25. Further review showed the resident was transferred to an acute care hospital setting following the insulin administration utilizing the wrong type of syringe. e. Review of nursing report titled; Supplemental Statement of Events dated 7/19/25 showed RN #1 documented 8 units of insulin was administered to the resident at approximately 4:30 PM on 7/18/25.
Further review showed the resident was not acting like him/herself and exhibited diaphoresis, cool skin, rapid breathing, and changes in level of consciousness. f. Review of the hospital physician note dated 7/19/25 showed the resident was admitted to the Intensive Care Unit for management for hypoglycemia and hypotension following accidental insulin overdose. g. Interview with RN #1 on 8/19/25 at 10:08 AM confirmed the resident was administered 80 units of insulin instead of 8 units on 7/18/25 at approximately 4:30 PM. She revealed during administration of the insulin, she utilized a tuberculin syringe instead of an insulin syringe because she couldn't find any insulin syringes.h. Interview with the director of nursing on 8/19/25 at 9 AM confirmed the wrong insulin dose was administered due to the nurse utilizing the wrong syringe for administration.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Sublette County Health in Pinedale, WY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Pinedale, WY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Sublette County Health or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.