Failure to Prevent Significant Medication Errors
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration procedures. One resident with diagnoses including dementia, respiratory failure, and thrombocytopenia was given another resident's medications, which included antihypertensives and an opioid, resulting in acute changes in condition such as low blood pressure, decreased responsiveness, and lethargy. The resident attempted to alert the nurse that the medication cup did not have her name, but the nurse insisted the medications were correct. The resident subsequently took the medications, became increasingly lethargic, and was sent to the hospital, where she was treated for accidental overdose and recovered after receiving Narcan. Another resident, with a history of malnutrition, hypertensive heart disease, and traumatic brain injury, received his roommate's medications after the two switched sides of their shared room without the change being updated in the electronic medical record (EMR). The nurse administering medications did not verify the residents' identities using updated photos or other identifiers, resulting in the resident receiving the wrong medications. This resident became unusually lethargic and was monitored closely after the error was discovered. The error was identified when the roommate reported that the nurse had attempted to give him morphine, which he did not take, and that his roommate had received a large number of pills. In both cases, the medication errors were directly linked to failures in verifying resident identity and following established medication administration protocols. Staff interviews confirmed that the nurses involved did not consistently use the required checks, such as confirming the resident's name, photo, or other identifiers, before administering medications. The errors were further compounded by issues such as pre-pouring medications and not updating room assignments in the EMR, which contributed to the confusion and subsequent administration of incorrect medications.