Failure to Identify Resident Results in Significant Medication Error and Hospitalization
Penalty
Summary
A significant medication error occurred when a Certified Nurse Assistant-Medication (C.N.A.-M) failed to properly identify a resident prior to administering medications, resulting in the resident receiving another individual's prescribed medications. The medications administered in error included Eliquis, Metformin, Flexeril, Lyrica, Furosemide, Potassium chloride, Risperidone, and Vitamin B. This action was not in accordance with the facility's General Dose Preparation and Medication Administration policy, which requires verification of the correct medication, dose, route, rate, time, and resident identity each time medication is administered. Following the administration of the incorrect medications, the resident exhibited lethargy and poor oxygen perfusion, necessitating transport to the emergency room for evaluation. Clinical documentation indicated that the resident was initially stable with mild drowsiness, but later became unresponsive, prompting emergency services to be called. The resident was evaluated at the hospital, where all laboratory results and blood sugar levels were within normal limits, and was subsequently returned to the facility while still lethargic, as expected by the hospital physician.