Resident Ingests Another Resident's Medications Due to Medication Cart Error
Penalty
Summary
Facility staff failed to prevent an accident when a resident ingested another resident's medications. The incident occurred when a certified medication technician (CMT) was preparing medications for one resident and placed the cup of medications for a second resident on top of the medication cart. While the CMT was distracted by a request from an LPN to check the LPN's blood glucose, the first resident reached over, picked up the cup containing the second resident's medications, and ingested them. The facility's medication administration policy required staff to verify resident identity three times before administering medication, ensure the right medication, dosage, time, and route, and to keep medications inaccessible to residents by not leaving them on top of the cart. In this case, the CMT did not follow these procedures, as the medications were left on top of the cart and accessible to residents, and the CMT was distracted by another task during medication administration. The resident who ingested the wrong medications was assessed as cognitively intact and independent with ambulation. The medications ingested included Haloperidol, Atorvastatin Calcium, and Clozaril, none of which were ordered for this resident. Following the ingestion, staff assessed the resident, monitored vital signs, and notified the appropriate medical personnel.