Significant Medication Error Due to Miscommunication and Failure to Follow Protocol
Penalty
Summary
Facility staff failed to ensure that residents remained free from significant medication errors when a certified medication technician (CMT) administered a medication cup containing ezetimibe, simvastatin, Vistaril, or trazodone to a resident who did not have physician orders for these medications. The error occurred when the CMT, unfamiliar with the residents on the hall, was handed a pre-prepared medication cup by a nurse and subsequently gave it to the wrong resident in a shared room. The resident who received the incorrect medications was assessed as severely cognitively impaired with a diagnosis of Parkinson's disease. Progress notes documented that the resident became quite sedated after receiving the medications and required education on fall risk due to the sedative effects. The facility's medication administration policy required staff to use two identifiers and ensure medications were administered per physician orders, but this protocol was not followed. The CMT admitted to giving a medication cup to the wrong resident after a miscommunication with the nurse, who had prepared the medications. The resident's physician was notified after the error, and the resident was monitored throughout the night. The incident was documented in the facility's investigation, and staff interviews confirmed the sequence of events leading to the medication error.