F0760

D

Significant Medication Error When One Resident Received Another Resident’s Medications

Wallingford, Connecticut Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident received medications prescribed for another resident. Resident #1, who had vascular dementia, Parkinson’s disease, and anxiety disorder, had moderately impaired cognition and required maximum assistance with personal care. Resident #1’s care plan included use of antipsychotic medications for Parkinson’s-related hallucinations, with directions to administer medications per physician orders and monitor for side effects and effectiveness. On the evening in question, Resident #1 received his or her scheduled medications, including multiple agents for cholesterol, diabetes, Parkinson’s disease, hypertension, constipation, pain, and neuropathy.

Resident #2, who had bipolar disorder, Type 2 diabetes mellitus, and atherosclerotic heart disease, also had moderately impaired cognition and required moderate assistance with personal care. Resident #2’s care plan addressed mood problems related to major depressive disorder, bipolar disorder, and anxiety disorder, with directions to administer medications per physician orders and monitor for side effects and effectiveness. On the same evening, Resident #2 refused several medications, including atorvastatin, Belsomra, lurasidone, trazodone, buspirone, carvedilol, doxycycline, and metformin, and requested they be given later. The LPN labeled a medication cup with Resident #2’s name and placed it back into the medication cart instead of disposing of the refused medications.

Later that night, the LPN gave the pre-poured, labeled cup of Resident #2’s medications to a nursing assistant and asked the assistant to administer them to Resident #2, despite facility policy and the DNS’s stated standard of practice that only licensed personnel prepare and administer medications and that refused medications be disposed of immediately. The nursing assistant, who acknowledged knowing that only licensed nurses were to administer medications, took the cup into the shared room and administered the medications to Resident #1 instead. This error was discovered after Resident #2 requested pain medication, and it was recognized that the medications given by the nursing assistant to Resident #1 were intended for Resident #2. Resident #1 was subsequently found to have received additional medications including trazodone, lurasidone, buspirone, carvedilol, doxycycline, and metformin, and developed encephalopathy, which the physician identified as more likely related to trazodone toxicity or possibly metabolic encephalopathy in the setting of RSV infection and hypoxia. The physician also identified that the total doses of metformin, tramadol, and the combination of carvedilol with previously administered metoprolol placed the resident at risk for low blood sugar, hypotension, drowsiness, lethargy, nausea/vomiting, and decreased blood pressure and heart rate.