Significant Medication Error Due to Unattended Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by an incident involving two residents. An LPN prepared medications for two residents at the same time, labeling both medication cups, and left one resident's medications unattended at the bedside of another resident. The resident, who was cognitively intact and had a history of hypertension, atrial fibrillation, and heart failure, ingested the medications intended for their roommate. Facility policy specifically prohibits preparing medications in advance or leaving them for self-administration outside of a nurse's supervision, and there was no documented order or assessment for the resident to self-administer medications. Following the ingestion of the wrong medications, the resident received an overdose of blood pressure and heart medications, including metoprolol and lisinopril, in addition to their prescribed regimen. This resulted in severe bradycardia and significant hypotension, with blood pressure readings dropping as low as 62/36. The resident experienced symptoms such as nausea, vomiting, lethargy, and episodes of diarrhea, and ultimately developed acute kidney injury due to hypotension and acute tubular necrosis. The resident required continuous monitoring, frequent reassessments, and was eventually transported to the hospital for further treatment and monitoring in the intensive care unit. Interviews with facility staff, including the LPN involved, the DON, and the administrator, confirmed that medications should not be left unattended in resident rooms and that staff are educated on this policy. Despite this, the LPN became distracted during the medication pass and left the medications at the bedside, leading to the error. The medical director confirmed that the incident constituted a significant medication error and emphasized that medications should be administered to one resident at a time under direct observation.