F0684

G

Wrong-Resident Medication Administration Without Physician Orders Leading to Hospitalization

Tucson, Arizona Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that medications administered to a resident had corresponding physician orders, resulting in a significant medication error. A resident with metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit, syncope and collapse, and a history of TIA was admitted for inpatient rehabilitation. The resident’s medications had been reviewed and reconciled, and active physician orders included medications such as clopidogrel, propranolol ER, lamotrigine, heparin, and others, all of which were documented as administered per the eMAR. The resident had a BIMS score of 05, indicating severe cognitive impairment, and was documented as receiving anticoagulants, antiplatelets, and injectable medications.

On the day of the incident, a nurse assigned to another resident prepared that other resident’s medications and went to administer them. When the intended resident was not in their room, the RN went to the therapy gym and asked therapists to locate the other resident. A physical therapist assistant, who had not previously met either resident, told the RN that he had the other resident, and the resident being treated in therapy also verbally identified herself as that other resident. The RN, who had limited prior exposure to this resident and had never worked on that hall before, then administered the prepared medications to the resident in therapy. These medications included amiodarone, aripiprazole, aspirin 325 mg, citalopram 40 mg, apixaban 2.5 mg, ferrous sulfate, folic acid, Lasix 40 mg, midodrine 10 mg, a multivitamin with minerals, potassium ER 20 mEq, vitamin B12 1000 mcg, and vitamin D3 1000 IU, none of which had physician orders for this resident.

Approximately 20 to 40 minutes later, the PTA realized while escorting the resident back to her room that the medications had been given to the wrong resident and informed the RN and DON. Documentation and interviews show that the resident’s morning vital signs had been within normal limits prior to the event. Later that afternoon, when the resident’s family arrived, they found the resident slumped over in a wheelchair, unresponsive to verbal cues but responsive to physical stimulation, unable to state her birthday, the current year, or her location, and with eyes rolling back and falling asleep immediately afterward. Nursing documentation recorded a blood pressure of 162/81 and a change in condition, and the family reported that the resident could not lift her head and that her blood pressure had “skyrocketed.” The facility’s own policies on oral medication administration and quality of care required that no medication be administered without a physician’s order and that residents be properly identified before medication administration, but these requirements were not followed in this incident, leading to the administration of multiple medications without orders and subsequent hospitalization for unintentional use of medication and elevated blood pressure.

Interviews with involved staff further detailed the actions and inactions that led to the deficiency. The LPN assigned to the resident that day stated she had correctly administered the resident’s ordered medications earlier in the shift and later learned from another nurse that medications intended for a different resident had been given to her resident in the therapy gym. The DON explained that staff were expected to verify resident identity using name, date of birth, door tags, and EMR photos, and that no medication should be given without a physician’s order, but acknowledged that the RN had relied on the PTA’s statement and the resident’s verbal confirmation in the group therapy setting. The PTA admitted he should have taken more time to verify the resident’s identity and that he believed he was working with the other resident when he told the RN he had that person. Collectively, these actions and failures in resident identification and adherence to medication administration policy resulted in the resident receiving multiple medications without physician orders and experiencing a documented change in condition requiring hospital admission for observation and unintentional medication use.