Medication Error When Precepting Nurse Prepares Medications for Another Nurse
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when one resident received another resident’s medications, including insulin and antihypertensive medication. The affected resident had multiple diagnoses, including depression, thyroiditis, GERD, osteoporosis, dementia, hypercholesterolemia, sleep apnea, insomnia, chronic pain, and dysphagia. The resident and a family member both reported that the resident had been given the wrong medications, with the family member specifically noting insulin and a blood pressure medication. The resident recalled receiving the wrong medication but could not identify which medications or when the incident occurred. Record review showed that on the morning in question, the resident was administered a full set of medications that were ordered for another resident with chronic respiratory failure, type 2 diabetes, depression, PTSD, hypercholesterolemia, anxiety, mild cognitive impairment, dementia, dysphagia, hypertension, and cognitive communication deficit. The medications given in error included Farxiga 10 mg, hydrochlorothiazide 25 mg, furosemide 20 mg, loratadine 10 mg, a multivitamin, potassium chloride 10 mEq, acetaminophen 650 mg, Lantus 22 units subcutaneously, and metoprolol tartrate 25 mg. The resident’s blood sugars were monitored and documented following the error, and the medication administration record showed that the resident’s own scheduled 0800 medications were held that day. Interviews with facility staff revealed that the error occurred during orientation of a new LPN. The precepting RN pulled and documented the medications for the other resident in the electronic system because the orienting LPN did not yet have access to the electronic MAR. The RN then handed those medications to the LPN to administer. The LPN reported that she did not follow the five rights of medication administration and mistakenly gave the medications to the wrong resident. The regional clinical consultant identified that the root cause was the LPN not pulling the medications herself and not following the five rights, and that professional practice standards requiring the same person to both pull and administer medications were not followed.
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