Medication Administration Error Resulting in Unnecessary Drug Administration
Penalty
Summary
A deficiency occurred when a medication technician administered medications to a resident that were prescribed for the resident's roommate. The medications given in error included Donepezil, Namenda, Senna, and Plavix, none of which were ordered for the resident who received them. The resident who received the medications had a history of chronic kidney disease stage 3, anemia, essential hypertension, and unspecified dementia with anxiety, and was noted to have severe cognitive impairment based on a recent assessment. Review of the medication administration records confirmed that these medications were not prescribed for the resident who received them, but were instead prescribed for the roommate. The incident was discovered after a registered nurse realized that the medications intended for the resident in the bed by the window were instead given to the resident in the bed by the door. The nurse had handed the medication cup to the technician with instructions, but the technician administered the medications to the wrong resident. The Director of Nursing acknowledged that the resident had received unnecessary medications as a result of this error.