Significant Medication Error Due to Double Administration
Penalty
Summary
A deficiency occurred when a resident with diagnoses of high blood pressure, dementia, and anxiety was administered a double dose of their morning medications. The incident happened after the resident requested their medications from an LPN, who, due to a lack of clear communication and documentation between nursing staff during a shift change, provided the medications without realizing they had already been administered by the previous nurse. The medications given twice included Aspirin, Centrum Silver, Isosorbide Mononitrate Extended Release, and Lisinopril-Hydrochlorothiazide. Following the double administration, the resident exhibited mild shortness of breath and hypotension, prompting a call to the physician and subsequent transfer to the emergency room. The facility's policy required medications to be administered as prescribed and documented immediately after administration. However, the LPN was unable to document the administration in the electronic medical record at the time and relied on verbal communication, which led to the oversight. The Director of Nursing confirmed that the facility failed to ensure residents are free from significant medication errors, as required by state regulations.