Medication Administration Error: Gabapentin Given to Wrong Resident
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered Gabapentin 600 mg, which was prescribed for one resident, to another resident in error. The resident who received the medication in error had an active order for Gabapentin 800 mg to be given four times daily, but instead received a one-time dose of 600 mg, which was not their prescribed dose at that time. The LPN recognized the error, contacted the physician, and obtained a one-time order for the 600 mg dose for nerve pain, but the medication originally belonged to another resident. The incident involved two residents: one with diagnoses including orthopedic aftercare, cerebral palsy, and anxiety disorder, and another with hemiplegia, chronic obstructive pulmonary disease, and bipolar disorder. The error was confirmed through interviews with the LPN and the Director of Nursing (DON), who acknowledged that the Gabapentin 600 mg administered to the first resident was actually intended for the second resident. This event was identified during a review of medication administration records and staff interviews.