Medication Error During LPN Orientation Leads to Wrong-Resident Administration
Penalty
Summary
The deficiency involves nursing staff failing to follow professional standards for medication administration, resulting in one resident receiving another resident’s medications. Resident #1 was admitted with multiple diagnoses including depression, thyroiditis, GERD, osteoporosis, dementia, sleep apnea, insomnia, chronic pain, dysphagia, and hypercholesterolemia. On the date of the incident, Resident #1 received a full set of morning medications that had been ordered for Resident #7, including Farxiga 10 mg, hydrochlorothiazide 25 mg, furosemide 20 mg, loratadine 10 mg, a multivitamin, potassium chloride 10 mEq, Tylenol 650 mg, Lantus 22 units subcutaneous, and metoprolol tartrate 25 mg. Resident #1 later recalled receiving the wrong medication but could not recall the specific drugs or the date, and reported no negative outcome. Resident #7 had been admitted with chronic respiratory failure, type 2 diabetes, depression, PTSD, hypercholesterolemia, anxiety, adjustment disorder, mild cognitive impairment, dementia, dysphagia, hypertension, and a cognitive communication deficit, and had a BIMS score of 12, indicating moderate cognitive impairment. The medications administered to Resident #1 were those ordered for Resident #7. Review of Resident #1’s medical record showed that blood sugars were monitored following the event, with readings of 126 mg/dL, 150 mg/dL, 218 mg/dL, and 123 mg/dL over the subsequent hours. Resident #1’s October MAR showed that all of her own 0800 medications, including alendronate, cholecalciferol, duloxetine, fenofibrate, hydrochlorothiazide, losartan, clonidine, and famotidine, were held that morning. Interviews revealed that the error occurred during orientation of a new LPN. The Nursing Home Administrator and Regional Clinical Consultant stated that an RN preceptor pulled the medications for Resident #7 from the medication cart and then handed them to the LPN, who was on orientation and did not have access to the electronic MAR in PointClickCare. The LPN then administered these medications to Resident #1 instead of Resident #7 and acknowledged not following the five rights of medication administration (right patient, right medication, right dose, right time, right route). The Regional Clinical Consultant stated that professional practice dictates that the person who pulls the medication should be the one to administer it, and that this standard, as well as the five rights, were not followed in this incident.
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