Resident Given Another Resident's Medications Due to LPN Error
Penalty
Summary
A medication administration error occurred involving a resident with diagnoses including hypertension, depression, anxiety, and a history of acute renal failure. The resident, who was alert and oriented, was mistakenly given another resident's 9:00 AM medications. The error happened when the LPN, while preparing medications for two residents, was called to assist a physical therapist with the resident. The LPN brought both residents' medication cups into the room, placed them on the bedside table, and after assisting the resident, administered the wrong set of medications without verifying them. The LPN did not follow the facility's medication administration policy, which requires adherence to the six rights of medication administration. The medications administered in error included drugs for prostate enlargement, hypertension, stomach acid reduction, and blood thinners, which were not prescribed for the resident who received them. The incident was immediately recognized by the LPN, who reported it to the nursing supervisor. Facility documentation and interviews confirmed that the LPN failed to secure the medications and did not verify the correct medications before administration, directly leading to the deficiency.