Duplicate Carvedilol Doses Left at Bedside Lead to Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when duplicate doses of a prescribed blood pressure medication were administered. The resident had diagnoses including metabolic encephalopathy and hypertension and was assessed as severely cognitively impaired with a BIMS score of 5/15. The resident had an order for carvedilol 25 mg by mouth twice daily with meals for hypertension, scheduled for morning and evening, and there was no order or care plan for self-administration of medications. According to the Medication Administration Record, an LPN documented administering the resident’s evening medications, including carvedilol, on the day prior to the incident. The facility’s investigative summary later determined that whole medications, identified by the resident’s daughter as likely carvedilol and atorvastatin, had been left at the bedside by staff from a previous shift. On the morning of the incident, family members arrived and found a couple of pills in a medicine cup on the bedside table; the daughter reported that the resident ingested these pills before the nurse began the morning medication pass. While the LPN was administering the scheduled morning dose of carvedilol crushed in applesauce, the daughter informed the nurse that the resident had just taken two pills from the bedside. The LPN checked the MAR and, after comparing pill appearance with the daughter’s description, concluded the pills were likely the resident’s blood pressure medication from the prior evening. Despite this, the crushed carvedilol dose in applesauce was administered. Within approximately 30–45 minutes, the resident became drowsy, then unresponsive to verbal and tactile stimuli, and vital signs showed a significant drop in blood pressure (78/54) with altered consciousness. The resident was transferred to the ED, where records indicated hypotension and bradycardia after taking two doses of carvedilol earlier that day.
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