Medication Error Leads to Hospitalization for Hypoglycemia
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including Type 2 diabetes mellitus and Alzheimer's disease, was inadvertently administered another resident's morning medications by an LPN. The LPN, unfamiliar with some residents due to infrequent work shifts, asked the resident her name, received the name of a different resident, and proceeded to give her that resident's medications. The error was only discovered after a CNA identified the resident and the LPN realized the mistake. The medications administered included several drugs, notably antidiabetic agents such as Januvia and Metformin, which were not prescribed for the resident. Following the administration of the incorrect medications, the resident was found to have a critically low blood glucose level (44 mg/dL), for which she was given orange juice to raise her blood sugar. Despite this intervention, the resident remained lethargic and more confused than her baseline. Emergency services were called, and the resident was transported to the hospital, where she was admitted for hypoglycemia. Hospital records confirmed the resident had been given another resident's medications, resulting in hypoglycemia that required intravenous dextrose and close monitoring until her blood sugars stabilized. The facility's medication administration policy requires verification of the five rights (right resident, right drug, right dose, right route, right time) with a triple check process, but this protocol was not followed in this instance. The LPN did not verify the resident's identity beyond asking her name, which was unreliable due to the resident's severe cognitive impairment. Additionally, the facility was unable to provide a specific policy for medication errors when requested during the survey.