F0760

G

Resident Given Another Patient’s Medication Regimen During Therapy Session

Tucson, Arizona Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a full set of medications prescribed for another resident was administered in error. The affected resident had multiple diagnoses, including metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit, and syncope and collapse, and had active physician orders for a specific regimen of medications such as clopidogrel, fluconazole, loratadine, propranolol ER, lamotrigine, acetaminophen, and heparin, among others. These ordered medications were correctly transcribed to the MAR and documented as administered as ordered earlier in the day.

Later that day, an RN who was responsible for another resident’s medications 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 intended resident. A PTA, who had not previously met either resident, told the RN that he had the intended resident, and the resident being treated in therapy also verbally identified herself as that other resident. Without further verification, the RN administered the other resident’s medications to this resident. The list of medications given in error, as documented in a handwritten note by an LPN, included amiodarone, aripiprazole, aspirin, citalopram, apixaban, ferrous sulfate, folic acid, furosemide (Lasix), midodrine, a multivitamin with minerals, potassium ER, vitamin B12, and vitamin D3, none of which had physician orders for this resident.

Following the administration of the wrong medications, staff became aware of the error approximately 20–40 minutes later when the PTA realized that the resident he was escorting back to her room was not the intended resident and informed the RN and DON. Documentation shows that the resident’s vital signs were monitored, with a morning blood pressure of 140/72 and later a blood pressure of 162/81. A nursing note described that when the family arrived, the resident was slumped over in her chair, not responding to verbal cues but responding to physical stimulation, unable to state her birthday, the current year, or her location, and with eyes rolling back and falling asleep immediately afterward. The family reported finding the resident slumped over in a wheelchair with no staff present, having to seek help, and being told that the resident had been given medications intended for another resident, including medications to treat schizophrenia. The facility’s own policy on oral medication administration required that no medication be given without a physician’s order and that the resident be identified before administering any medications, which was not followed in this incident.

Interviews with staff further detailed the actions and inactions that led to the error. The RN stated she had never worked on that hall before, had only seen the resident once previously, and relied on the PTA’s statement and the resident’s verbal confirmation to identify the resident before administering the medications. The PTA acknowledged that he had not met either resident before that day and that he believed he had the intended resident but did not take additional steps to verify identity. The DON stated that staff were expected to verify resident identity using name, date of birth, door tag, and photo in the electronic record, and that in this case the resident received medications prescribed for another resident while in a group therapy session after being misidentified by both the PTA and the RN. These combined failures in resident identification and adherence to the facility’s medication administration policy resulted in the resident receiving multiple medications without physician orders and experiencing a subsequent change in condition, including altered responsiveness and elevated blood pressure, leading to hospital admission with a diagnosis that included unintentional use of medication.