F0760

G

Significant Medication Error Leading to Iatrogenic Hypotension

Huntley, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, resulting in iatrogenic hypotension and hospitalization. The resident was an elderly female admitted with multiple complex diagnoses, including cellulitis of both lower limbs, sepsis, anemia in chronic kidney disease, hypertensive heart and chronic kidney disease, acute pulmonary edema, paroxysmal atrial fibrillation, chronic congestive heart failure, and venous insufficiency. Her admission and initial nursing assessments documented that she was generally alert to person and time, oriented to person and place, but confused at times. On the morning of the incident, nursing documentation indicated that she was in bed at the start of the shift without distress, and later seated in a chair during the morning medication pass with no complaints or observable concerns. A nursing assessment around 10:00 a.m. reportedly showed findings within normal limits and consistent with her baseline, and her scheduled morning medications were administered per physician orders with no immediate adverse reactions observed.

The events leading to the medication error centered on the actions of an LPN who was passing morning medications. The LPN stated that the resident was new to the facility and that she checked the photograph in the electronic system, which she believed matched the resident. She then approached the resident, who was sitting near the nurse’s station in a wheelchair, and asked if her name was that of another resident with a different medication profile. According to the LPN, the resident nodded and verbally affirmed that name. The LPN reported that she checked vital signs and believed the blood pressure was within acceptable parameters, then prepared and administered the other resident’s medications to this resident. The facility’s documentation showed that the other resident’s 9:00 a.m. medication regimen included venlafaxine, furosemide, carvedilol, Entresto, Procardia, aspirin, and clopidogrel, and the DON later specified that the affected resident actually received venlafaxine, furosemide, aspirin, Entresto, iron, omeprazole, oxybutynin, and Procardia, in addition to her own prescribed Bumetanide. The resident did not normally receive blood pressure medications.

After the incorrect administration, the other resident whose medications had been intended approached the nurse’s station questioning her morning medications and stating she did not want them and wanted to discharge. This prompted staff to realize that the medications had likely been given to the wrong resident. The RN who assessed the affected resident found her at the nurse’s station with her head slumped to the side, very lethargic, and no longer at her reported baseline of being alert and oriented to person and time. The RN obtained a blood pressure reading around 64/40 and described the pulse as so faint that a manual blood pressure could not be obtained reliably; paramedics later reported a blood pressure in the range of 55/30. The medical director, who was present in the facility, also attempted to check the blood pressure and found it very feeble. The resident’s daughter reported that the hospital informed her that the resident had been given her own medications plus another resident’s medications, including four different blood pressure-lowering medications, and that the resident was in “shock,” requiring IV medications to raise her blood pressure, ICU care, and involvement of poison control. Hospital discharge paperwork listed a diagnosis of iatrogenic hypotension. The facility’s own policies required that residents be correctly identified prior to medication administration by checking the photograph and/or asking the resident to identify themselves by name, and explicitly stated that medications prescribed for one resident shall not be administered to another resident, as well as emphasizing correct resident identification in medication pass guidelines.