Wrong-Medication Administration to Resident With Same First Name
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to adequate care and treatment during medication administration, resulting in the resident receiving another resident’s medications. The resident, who was in the facility for therapy after falling in his kitchen and cracking his hip, reported that a nurse who was not his regular nurse entered his room in the morning and gave him a handful of 4–5 pills, including a blue pill, along with a chocolate nutritional drink and a nasal spray. The resident stated the nurse did not ask his name, he had no ID bracelet on, and he told the nurse he did not receive a nasal spray and did not like chocolate nutritional drinks. He also reported that the nurse appeared to be looking for an IV port and IV equipment in his room, which he did not have, while a male resident in the next room with the same first name did have an IV pole. The resident later went to therapy, where his regular nurse brought his usual medications, prompting him to realize he had received extra medications earlier. He reported feeling lightheaded and “high,” describing the sensation as if he had smoked multiple marijuana cigarettes, and his brother, who was with him, commented that he looked high. The resident stated he informed staff, but he did not recall all details because he felt “out of it.” The facility’s investigative report documented that the family raised concerns about a medication error, and that the resident reported receiving medications from one nurse and then again from another nurse that same morning, both calling him by his first name, though he only recognized his regular nurse. In a subsequent interview, the LPN who passed the wrong medications explained she had picked up an extra shift on a unit where she did not usually work and was assigned a specific medication cart and room range. She stated that two residents with the same first name were in side-by-side rooms and that she mistakenly administered medications intended for one resident, including an IV antibiotic order, to the other resident. She acknowledged that she went to the wrong room and gave the wrong medications to the wrong resident, and that the other resident did not receive those medications. Vital sign records for the affected resident showed documentation at 1:37 a.m. and then not again until early evening that day, with no vital signs recorded around the time of the morning medication error.
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