Failure to Monitor and Notify After Medication Error Leads to Resident Hospitalization
Penalty
Summary
A resident with multiple medical conditions, including dementia, diabetes, bradycardia, and aortic valve stenosis, was admitted to the facility and had significant cognitive impairment, being rarely or never understood and having severely impaired decision-making skills. On the morning in question, a registered nurse administered another resident's medications, including 200 mg of Clozapine and 80 mg of Geodon, to this resident in error. The nurse failed to properly identify the resident, despite the resident wearing a name band, and the error was only recognized after the medications were ingested. Documentation indicates that the resident remained in the dining area for supposed monitoring, but vital signs were not taken in real time, and the note was not entered until the following day. The nurse assigned to the resident did not assess the resident or ensure monitoring, relying on the other nurse's statement that monitoring had occurred. The facility failed to inform additional staff on the unit about the medication error, so no enhanced monitoring was provided. The resident's family, including the spouse who was present in the facility for about an hour after the error, was not informed of the incident. The resident was allowed to leave the facility on a leave of absence (LOA) with the spouse, who signed the resident out following protocol, but was unaware of the medication error. The nurse assigned to the resident did not review the LOA book and was unaware that the resident had left the facility. Other staff, including nursing assistants, were not informed of the need for monitoring and assisted with the LOA process without knowledge of the error. The provider was not notified of the medication error until approximately nine hours after the incident, after the resident had already been transported to the hospital by emergency medical services due to unresponsiveness. Documentation of vital signs in the resident's record was either delayed or used outdated information from a previous month. The medical director confirmed that the resident should not have been allowed to leave the facility and that no interventions or real-time monitoring were implemented following the error. As a result, the resident experienced adverse effects from the medications, required emergency hospitalization, and was placed on a ventilator for treatment of toxic metabolic encephalopathy.