Resident Administered Unprescribed Medications Resulting in Hospital Transfer
Penalty
Summary
A resident with diagnoses including heart failure, renal insufficiency, dementia, and paroxysmal atrial fibrillation was admitted with intact cognition, as indicated by a BIMS score of 13. During the night shift, a registered nurse administered three medications—Tizanidine, Cyclobenzaprine, and Diphenhydramine—that were not prescribed for the resident. Documentation from a certified nursing assistant indicated that the nurse acknowledged the resident did not have orders for these medications but stated they would help the resident sleep. The resident's medical record did not contain any physician orders for these medications. Following the administration of the unprescribed medications, the resident became increasingly lethargic, difficult to arouse, and combative with care, which was a change from their baseline. The resident was subsequently sent to the emergency department for evaluation, where laboratory tests and intravenous fluids were administered. The incident was reported to facility leadership, and the surveyor confirmed that the medications given were not ordered for the resident. No additional information was provided regarding the administration of these medications.