Resident Received Unprescribed Benzodiazepine Resulting in Hospitalization
Penalty
Summary
A facility failed to ensure that a resident was free from significant medication errors when a resident with moderate cognitive impairment and multiple medical diagnoses, including COPD, hypertension, and dementia, was found unresponsive and required emergency medical intervention. The resident was not prescribed any benzodiazepine medication, yet a drug screen at the emergency room revealed the presence of benzodiazepines in her system. The resident had received her scheduled medications, which did not include any benzodiazepines, from a certified nurse assistant/certified medication aide earlier that morning. Shortly after, she exhibited severe symptoms such as unresponsiveness, shaking, low blood pressure, and low oxygen saturation, necessitating ambulance transport to the hospital. The facility's investigation was unable to determine how the resident received the unprescribed benzodiazepine. Interviews with staff, including the medication aide who administered the morning medications, indicated that the resident was not near any other residents who were prescribed benzodiazepines at the time of administration. The resident's room was searched for unauthorized medications, and no evidence was found. The facility did not review the controlled medications in the medication carts after learning of the positive drug screen, and there was no indication that the medication could have been administered by hospital or ambulance staff. The resident's physician and consultant pharmacist confirmed that none of her prescribed medications could have caused a false positive for benzodiazepines. Facility policies required staff to follow the seven rights of medication administration and to ensure medications are administered only as prescribed, with verification of resident identity and observation of ingestion. Despite these policies, the facility could not identify the source of the medication error, and the resident's condition was directly linked to the ingestion of a benzodiazepine that was not ordered for her. The incident was reported to the state health department, and the facility acknowledged that a medication error had occurred, but the exact circumstances leading to the error remained undetermined.