Medication Error from Pre-Pouring and Wrong-Resident Administration
Penalty
Summary
The deficiency involves a failure to ensure a resident was free from significant medication errors when one resident was given another resident’s medications. The cognitively impaired resident had dementia and Alzheimer’s disease. Another resident had diagnoses including epilepsy and chronic pain and physician orders for Carbamazepine 400 mg at bedtime, Phenobarbital 97.2 mg at bedtime, and Tramadol 50 mg three times daily for pain. Progress notes showed that on the evening in question, an LPN administered this anticonvulsant and opioid medication regimen, which was ordered for the resident with epilepsy and chronic pain, to the cognitively impaired resident in error. According to the LPN’s interview, she prepared evening medications for both residents by placing each resident’s medications into separate medication cups. She was then abruptly called to another resident’s room and locked both cups in the medication cart. When she returned, she took the wrong cup and administered the medications intended for the resident with epilepsy and chronic pain to the cognitively impaired resident, stating she was in a hurry and did not verify that she had the correct medications for the correct resident. The Assistant DON stated that nurses are required to double check medications using the rights of medication administration and to administer medications immediately after preparation, and the facility’s Medication Administration policy specified that medications must be given to the right resident, with the right medication, dose, route, and time, and that medications may not be pre-poured and should be prepared and administered for only one resident at a time.
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