Medication Administration Error Involving Wrong Resident
Penalty
Summary
A medication aide (MA) administered multiple medications, including Tegretol, Lipitor, Baclofen, Metoprolol, Neurontin, and Quetiapine Fumarate, to a resident who did not have physician orders for any of these medications. These medications were prescribed for another resident, not the one who received them. The error occurred while the MA was passing medications and became distracted due to the presence of residents near the medication cart, which he had previously expressed caused him difficulty concentrating. The MA immediately recognized the error and reported it to the Assistant Director of Nursing (ADON) and Director of Nursing (DON). The resident who received the incorrect medications had a complex medical history, including Alzheimer's disease with early onset, essential hypertension, cognitive communication deficit, intermittent explosive disorder, psychotic disorder with hallucinations, dry eye syndrome, acute atopic conjunctivitis, and muscle weakness. At the time of the incident, the resident was observed to be active and alert, both before and after the medication error. Following the administration of the wrong medications, the resident was monitored, and her vital signs remained stable. However, the physician later ordered her transfer to the hospital for close observation. Facility records and interviews confirmed that the resident did not have any physician orders for the medications administered in error. The facility's policies required staff to verify resident identity and medication details before administration, but these procedures were not followed in this instance. The error was documented in the medication error report, and the incident was confirmed through interviews with the MA, ADON, DON, and other staff members. The resident was subsequently discharged from the hospital with no new orders and returned to her baseline condition.