Resident Hospitalized After Receiving Another Resident's Psychiatric Medications
Penalty
Summary
A significant medication error occurred when a registered nurse administered another resident's psychiatric medications, including 200 mg of Clozapine and 80 mg of Geodon, to a resident who was not prescribed these drugs. The nurse failed to properly identify the resident before administration, despite the resident wearing a name band, and relied on verbal confirmation, which was misunderstood. The error was discovered only after the medications had been ingested, when another staff member familiar with the residents identified the mistake. The affected resident had a complex medical history, including type 2 diabetes, dementia, bradycardia, and aortic valve stenosis, and was severely cognitively impaired, rarely understood, and had both short- and long-term memory problems. After receiving the incorrect medications, the resident became unresponsive while on a leave of absence with family, requiring emergency medical services. The resident was found slumped over, with shallow respirations and low blood pressure, necessitating oxygen, intravenous fluids, and mechanical ventilation during transport to the hospital. Hospital records confirmed the resident was treated for toxic metabolic encephalopathy due to accidental overdose of Clozapine. Facility records showed there was no physician's order for Clozapine or Geodon for this resident, and the error was not immediately communicated to the family or the hospital. The Director of Nursing and the Medical Director acknowledged the failure to follow medication administration policy and the lack of proper resident identification. The incident resulted in the resident being at risk for serious harm, injury, impairment, or death, and required hospitalization and intensive medical intervention.