Resident Received Another Resident's Medications Due to Medication Administration Error
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, and dependence on renal dialysis, was administered another resident's morning medications in error. The resident's care plan included interventions to administer medications as ordered, and the resident was identified as being at risk for dehydration, fluid imbalance, and pain related to several chronic conditions. On the day of the incident, the resident did not receive their scheduled morning medications and instead received a full set of medications intended for another resident. The medications administered in error included several drugs with significant potential side effects, such as amlodipine, atorvastatin, duloxetine, Eliquis, furosemide, gabapentin, potassium chloride, sotalol, and atenolol. The resident had a documented allergy to atorvastatin, with previous reactions of dizziness and rash. At the time of the incident, the resident was assessed and found to have no immediate signs or symptoms of adverse effects, and no rash was present. The resident was later sent to the hospital due to symptomatic bradycardia and ongoing concerns related to his medical history, including orthostatic hypotension and dialysis needs. Interviews with facility staff, the resident's family member, and the nurse practitioner confirmed that the resident received the wrong medications and did not receive his own scheduled medications. The facility's medication administration policy required verification of the five rights of medication administration, including resident identification, but this process was not followed, resulting in the medication error.