Significant Medication Error Due to Improper Administration
Penalty
Summary
A significant medication error occurred when a staff member administered losartan 100 mg and gabapentin 100 mg to a resident who was not prescribed these medications. The incident was observed by another staff member, who witnessed the resident verbally refusing the medication and questioning what was being given. Despite the resident's refusal and expressed confusion, the staff member proceeded to place a spoon in the resident's mouth and administered the medications. The error was later confirmed through review of the resident's progress notes and staff interviews. The provider documented that the resident inadvertently received the medications and outlined the symptoms to monitor as a result. The Director of Nursing acknowledged that the medication error was substantiated, while the associated abuse allegation was deemed inconclusive. The incident was identified during a review of a facility-reported incident and corroborated by a witness statement from another staff member.