Significant Medication Error Due to Failure to Verify Medication Administration
Penalty
Summary
A deficiency occurred when a moderately cognitively impaired resident, who was dependent on staff for medication administration, was given another resident's morning medications in error. The incident took place during a medication pass when one LPN, who was being trained by another LPN, was handed a cup of medications intended for a different resident. The assisting LPN did not verify the medications or check the physician's orders before administering them. As a result, the resident received a combination of medications including antihypertensives, antiplatelets, and dementia medications that were not prescribed for them. Following the administration of the incorrect medications, the resident became acutely symptomatic, experiencing dizziness and significantly low blood pressure. The resident's blood pressure readings remained low throughout the day, requiring multiple interventions including administration of midodrine and attempts to initiate intravenous fluids. The resident continued to report symptoms such as dizziness and hypotension, necessitating ongoing monitoring and additional doses of medication to manage blood pressure. The incident was identified after the resident reported feeling unwell and staff realized the medication error. Documentation and interviews confirmed that the error resulted from a failure to follow the facility's medication administration policy, specifically the requirement to verify the five rights of medication administration. The error was attributed to staff being behind on their medication pass and not properly verifying the medications before administration.