Significant Medication Error Leading to Hospitalization and ICU Admission
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when one resident was administered medications prescribed for another resident. Facility policy on Medication Administration, dated January 2025, required staff to review and confirm medication orders on the MAR and compare the medication label with the MAR, and to follow the Rights of Medication Administration, including using two resident identifiers and performing triple checks for the right drug and right dose. Despite these requirements, a licensed nurse entered a resident’s room, asked if the individual was the intended resident, accepted the affirmative response without further verification, and proceeded to administer the scheduled 8:00 p.m. medications. The resident who received the medications in error had been admitted with diagnoses including unspecified sequelae of cerebral infarction, major depressive disorder, generalized anxiety disorder, and adult failure to thrive. On the evening of the incident, this resident was given nine medications that were ordered for another resident: hydralazine 50 mg, buprenorphine 8 mg sublingual, quetiapine 25 mg, prazosin 1 mg, clonidine 0.3 mg, lorazepam 0.5 mg, melatonin 5 mg, mirtazapine 45 mg, and atorvastatin 40 mg. The error was discovered only after another resident informed the nurse that the individual who received the medications was not the intended resident. Following the administration of the wrong medications, the resident was assessed and found to be awake but drowsy, with a blood pressure of 110/61 and an oxygen saturation of 72%, which improved to 94% after 2L supplemental oxygen was applied. Later that evening, the resident’s condition changed, with the resident becoming lethargic, only arousable to sternal rub, and snoring, and the blood pressure recorded as 51/73. The resident was sent to the emergency room, where hospital records documented admission with a diagnosis of accidental drug overdose, the need for intubation in the emergency department, and subsequent transfer to the intensive care unit. The facility’s leadership confirmed that this was a medication error that resulted in hospitalization.
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