F0760

D

Unattended Medicated Beverage Leads to One Resident Receiving Another’s Psychotropic Medications

Winslow, Arizona Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves a resident receiving prescription medications that were ordered for another resident, after those medications were left unattended in a beverage. One resident with severe cognitive impairment, who spoke and understood Navajo and had no prescription medications ordered, was care planned for confusion, forgetfulness, and inattention. This resident’s medication regimen consisted only of OTC products such as calcium carbonate, claritin, famotidine, lidocaine patch, Systane eye drops, and Tylenol. On one day, the resident was found lying on the dining room floor next to her chair, responsive but very tired, with slow speech, rapid respirations, hypotension, low oxygen saturation, and an inability to stand without assistance. Nursing documentation recorded these abnormal vital signs, and the on‑call provider ordered transfer to the ED for evaluation.

In the ED, documentation reflected that EMS had been called for concern that this resident had accidentally received another patient’s trazodone and Seroquel. The ED physician note recorded a report from the nursing home that the resident had ingested 150 mg of Seroquel and 75 mg of trazodone that had been mixed into another resident’s drink at breakfast. The ED assessment described the resident as mildly somnolent but arousable to voice, oriented x0, moving all extremities at baseline, with no bony extremity injury. Poison control was contacted and advised that the resident could return once at baseline, noting it could take several hours for her to be less sleepy. The resident was observed in the ED for several hours and then discharged back to the facility in stable condition.

The other resident involved also had severe cognitive impairment, with a care plan noting forgetfulness and confusion, and spoke and understood English. This resident had active orders for quetiapine totaling 150 mg in the morning and trazodone 25 mg three times daily. A progress note documented that this resident had a history of refusing medications when offered whole or crushed in pudding, and nursing staff had begun giving medications crushed in hot chocolate, which the resident accepted. On the day of the incident, the resident initially began drinking the hot chocolate with medications but then pushed the cup away and attempted to give it to another resident at the dining table. Video reviewed with the DON later showed this resident with a blue cup identified as containing medication, taking a sip, then handing the cup to the cognitively impaired resident, who appeared to drink from it; approximately 40 minutes later, the second resident slumped over and fell.

An LPN reported that the morning medication pass could be difficult because some residents would only take medications while eating, and that crushed medications were usually placed in pudding, though some residents preferred them in drinks such as Boost or hot chocolate. The LPN stated that, with this particular resident, they had learned that she did not like to be watched while taking medications and usually finished the entire drink once she picked it up. On the incident day, the LPN mixed the medications in hot chocolate, saw the resident sip from the cup, and then walked away before the drink was finished, acknowledging this was a poor judgment and that the resident should not have been left until the medication was gone. Later, when called to assess the resident who fell, the LPN found her lethargic but able to talk and move, unable to walk as usual, and observed that the medicated cup from the first resident was in front of the second resident’s place, leading the LPN to assume the second resident had ingested some of the medication.

The DON stated that expectations for nurses during medication administration included following the five rights (right drug, dose, resident, time, and route), attempting re‑administration if a medication was refused, and documenting and disposing of medications if still refused. The DON further stated that medications could be mixed in applesauce, pudding, or a drink with an order, but that nurses were expected to ensure residents took all of the medication delivered and that leaving medications unattended—including crushed medications in pudding or hot chocolate—was not acceptable. Facility policy on Medication Management specified that only medications ordered by a medical practitioner should be administered to a resident and that staff shall not leave medication unattended. The RN/LPN Charge Nurse job description included responsibility to ensure that prescribed medication for one resident is not administered to another.