Significant Medication Error and Inadequate Monitoring After Wrong Medication Administration
Penalty
Summary
A resident with diagnoses of heart failure, renal insufficiency, and stroke, and no cognitive impairment, was administered another resident's medications, specifically jardiance and gabapentin, which were not ordered for them. The error occurred during the morning medication pass, and the resident spat out most of the medications due to swallowing issues but ingested at least two or three pills, including a diabetic medication. The LPN involved did not recall all the medications ingested but identified one as a diabetic medication. The nurse did not receive or implement specific monitoring parameters from the provider, such as checking blood glucose levels, and did not document all assessments performed after the error. Later that day, the resident exhibited increased drowsiness and new stroke-like symptoms, prompting emergency medical services to be called. Upon EMS arrival, the resident was found to be unresponsive to verbal stimuli, diaphoretic, and hot, with a blood glucose level of 64 mg/dL. Facility policy required verification of resident identity and medication checks prior to administration, which were not followed in this instance. The medication error and subsequent lack of thorough monitoring and documentation contributed to the resident's acute change in condition and transfer to the emergency room.