Medication Administration Error Due to Failure in Resident Identification
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to administer medications according to professional standards, resulting in a resident receiving another resident's medications. Facility policy required staff to verify the '5 Rights' of medication administration and use two identification methods before giving medications. However, the LPN did not follow these procedures, and instead, administered a full set of medications intended for a different resident to the affected individual. The resident who received the incorrect medications had a medical history including coronary artery disease, Alzheimer's disease, and a previous stroke. After receiving the wrong medications, the resident exhibited symptoms such as hypoxia, vomiting, bradycardia, hypotension, and altered mental status. Emergency services were called, and the resident was treated with Narcan, atropine, and IV fluids before being transported to the hospital for further evaluation and management. The medications administered in error included a combination of narcotics, blood pressure medications, anticoagulants, diabetic medications, and other drugs, totaling 18 different medications. Interviews and facility investigation revealed that the LPN became distracted during the medication pass and did not use the required identification checks. The LPN was unaware of the best practices for medication administration, such as bringing the medication cart to each resident's room and verifying resident identity with photos in the electronic medical record. The Director of Nursing confirmed that the facility failed to provide care and services in accordance with accepted standards of practice by not ensuring medications were administered to the correct resident.