Medication Administration Error Resulting in Resident Receiving Another's Medications
Penalty
Summary
Facility staff failed to ensure that a resident remained free from accidents when one resident received another resident's medications. According to the facility's policies, staff are required to safeguard residents, provide emergency care as needed, and administer medications in accordance with physician orders, verifying the resident's identity prior to administration. On the day of the incident, an LPN prepared medications for two different residents. One resident initially refused their medications and requested to take them later, while the other also refused their medications. The LPN placed both sets of medications in the medication cart and became occupied assisting other residents. When the first resident later requested their medications, the LPN inadvertently placed the wrong medication cup on the cart without verifying the label. While the LPN was distracted retrieving a spoon, the resident picked up the cup containing the other resident's medications, mixed them with pudding, and ingested them. Review of records confirmed that the medications ingested were not prescribed for the resident who consumed them. Interviews with facility staff, including the administrator and DON, revealed that staff are instructed to verify resident identity and administer medications to one resident at a time. Both acknowledged that the LPN was overwhelmed and assisting multiple residents at the time of the error, which contributed to the failure to follow established medication administration protocols.