Significant Medication Error Resulting in Hospitalization
Penalty
Summary
A significant medication error occurred when a nurse administered a resident the medications intended for his roommate. The incident took place during the midnight shift, when the nurse, while managing two residents in the same room, set down a cup containing the roommate's medications on the wrong resident's tray table. After assisting both residents back into bed, the nurse inadvertently gave the medications to the wrong resident. The nurse realized the error immediately after administration and attempted to notify the physician and the Director of Nursing, but did not receive an immediate response. The affected resident had multiple complex medical diagnoses, including ischemic cardiomyopathy, atrial fibrillation, congestive heart failure, diabetes, acute kidney failure, and a recent femur fracture. Following the medication error, the resident initially showed no adverse reaction, but over the next several hours became increasingly lethargic, with fluctuating vital signs and eventually became unresponsive with increased secretions. Nursing staff documented these changes and communicated with the on-call provider, who advised monitoring and did not provide new orders despite the resident's declining condition. The resident's condition continued to deteriorate, and he was ultimately transferred to the hospital for further evaluation. Documentation shows that the medications administered in error included several anticonvulsants, a benzodiazepine, an antipsychotic, and a diabetic medication, none of which were prescribed for the affected resident. The facility's records indicate that the error was recognized and reported, but there were delays and gaps in provider response and follow-up documentation regarding the resident's significant change in condition.