Multiple Medication Administration Errors Due to Misidentification and Order Documentation Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of incorrect medications or dosages to several residents. One resident was administered another resident's scheduled medications, which included a large dose of extended-release morphine, after an agency LPN misidentified the resident. The error was discovered when the resident refused a medication not prescribed to him, but by that time, he had already ingested the other pills. The resident subsequently experienced prolonged side effects, including nausea, vomiting, lethargy, and refusal of meals, and required administration of Narcan to reverse the opioid effects. Another resident received an excessive dose of Trazodone due to a failure to discontinue a previous order when the dosage was increased, resulting in the resident receiving both the old and new dosages. The resident was informed of the error and reported no ill effects other than increased drowsiness. Additionally, a third resident was administered both Novolog and Aspart insulin due to an incorrectly documented order, rather than receiving only the prescribed Novolog with meals. The resident did not experience adverse effects, as her blood sugars had been running high. Interviews with staff revealed that proper resident identification protocols were not consistently followed, with reliance on visual identification and verbal confirmation that proved insufficient. The agency LPN involved in the morphine error was unfamiliar with the facility's bed numbering system, contributing to the misidentification. The DON and clinical director acknowledged the errors and the need for further staff education on using two resident identifiers and verifying medication orders to prevent such incidents.