Medication Administration Error Due to Failure to Follow Five Rights
Penalty
Summary
A medication administration error occurred when a Registered Nurse (RN) gave oral medications intended for one resident to another resident. The RN prepared medications for a resident with moderately impaired cognition and diagnoses including non-Alzheimer's dementia, Huntington's disease, anxiety, and difficulty walking. However, the RN mistakenly administered these medications—clonazepam and hydroxyzine—to a different resident who had severe cognitive impairment, was dependent in all activities of daily living, and also had diagnoses of non-Alzheimer's dementia and Huntington's disease. The error was identified approximately ten minutes later when the RN attempted to document the administration in the electronic Medication Administration Record and noticed the photo did not match the individual who received the medication. The resident who received the incorrect medications was assessed and initially showed no adverse reactions, with vital signs within normal limits. However, later assessments noted lethargy, decreased interactivity, and audible chest congestion. The resident's responsiveness fluctuated, with periods of alertness and interaction returning over the following days. The resident also experienced delayed swallowing and decreased appetite during the monitoring period. The incident was documented in the facility's records, and the staff followed the facility's protocol for assessment and monitoring. The facility's policy on medication administration requires staff to follow the five rights of medication administration, including verifying the right resident using two identifiers and administering medications as ordered by the physician. Staff interviews confirmed that the RN was aware of these requirements and had received education on the five rights. Despite this, the RN failed to follow the policy, resulting in the administration of medications to the wrong resident.