Significant Medication Error and Failure to Prevent Administration of Allergic Medication
Penalty
Summary
A significant medication error occurred when a nurse administered the entire evening medication regimen intended for one resident to another resident. The affected resident had a documented allergy to one of the medications, Trazodone, with a known reaction of altered mental status. The nurse failed to verify the correct resident and medication prior to administration, resulting in the resident receiving multiple medications not prescribed to him, including anti-seizure drugs, diabetes medication, and Trazodone. The nurse did not recall checking for allergies before administering the medications and could not specify which medications were given at the time of the incident. Following the administration of the incorrect medications, the resident exhibited symptoms such as drowsiness, slurred speech, and altered mental status. Neurological assessments and vital sign monitoring were inconsistently performed and documented, with several checks missing vital sign data. The nurse and other staff members involved did not consistently follow the facility's protocol for incident reporting, documentation, and investigation. The incident report did not list the specific medications administered, and there was confusion among staff regarding the resident's allergies and the medications involved in the error. Interviews with staff and the resident's representative revealed that the resident's condition deteriorated following the medication error, leading to hospitalization and a stay in the ICU. The nurse, DON, and other staff members provided inconsistent accounts of the events, the medications administered, and the actions taken in response to the error. The facility failed to ensure that medications were administered as ordered, that allergies were checked, and that appropriate monitoring and documentation occurred after the error, resulting in an Immediate Jeopardy situation.