Resident Hospitalized After Receiving Another Resident's Medications
Penalty
Summary
A significant medication error occurred when a certified medication staff member, while distracted during the morning medication pass, administered a set of medications intended for one resident to another resident. The medications included antipsychotics, antidiabetic agents, benzodiazepines, narcotics, and other drugs, some of which were Schedule II controlled substances that medication aides are not permitted to administer according to state regulations. The error was facilitated by the nurse providing narcotics to the medication aide to administer, and by the medication aide pre-pouring and leaving the medications unattended in the medication cart. The resident who received the incorrect medications had a medical history including heart failure, intellectual disabilities, and chronic obstructive pulmonary disease. After receiving the wrong medications, the resident was found lethargic, unresponsive, and with pinpoint pupils. Emergency interventions were required, including the administration of two doses of Narcan, EMS transport, and subsequent hospitalization. The resident also received activated charcoal in the emergency room due to the overdose. Facility records and staff interviews confirmed that the medication aide signed off the administration of the medications in the wrong resident's Medication Administration Record (MAR). The nurse involved acknowledged giving the narcotics to the medication aide, and both staff members confirmed the sequence of events that led to the error. The Director of Nursing Services also acknowledged that the resident received another resident's medications, resulting in the need for emergency medical treatment and hospital admission for overdose.