Significant Medication Error Resulting in Resident Harm
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered medications intended for a different resident to a resident with severe cognitive impairment. The medications given in error included long-acting Morphine Sulfate 30 mg (extended release), Trazodone 200 mg, and Ativan 1 mg, all in crushed form. The nurse had prepared the medications for a hospice patient in a neighboring room but, after being distracted by a call light and resident requests, mistakenly gave the wrong medications to the resident who was not prescribed these drugs. The error was realized when the LPN returned to the medication cart to document administration and noticed the discrepancy between the medications pulled and the resident's medication administration record. The resident who received the incorrect medications had a history of vascular dementia, atrial fibrillation, dysphagia, acute kidney failure, urinary tract infection, sepsis, cognitive communication deficits, and hypotension. The resident was severely cognitively impaired and required assistance with activities of daily living. Following the administration of the wrong medications, the resident developed severe sedation and became unresponsive within approximately 30 minutes. Facility staff attempted to administer Narcan but were unable to access it due to issues with the automated drug storage device and lack of intranasal supplies. Emergency medical services were called, and the resident was treated with Narcan by EMS and transported to the hospital for further care. The facility's policies required verification of the right resident, medication, dose, route, and time of administration, as well as adherence to manufacturer instructions, which specifically warn against crushing extended-release morphine due to the risk of overdose. The nurse failed to follow these procedures, resulting in the administration of a potentially fatal dose of medications not prescribed to the resident. The incident was investigated by the facility, law enforcement, and medical staff, and it was determined that the error was accidental and not due to neglect or criminal intent.