Medication Cup Mix-Up Leads to Two Residents Receiving Each Other’s Bedtime Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors when two residents received each other’s evening medications. On the evening in question, a nurse (RN 1) prepared bedtime medications for two residents whose rooms were next to each other and placed the medications into separate cups. RN 1 then mixed up the cups, resulting in each resident receiving the other’s prescribed bedtime medications. One resident, who was cognitively intact for daily decision making, questioned the number of pills because he did not usually take that many medications in the evening but proceeded to take them. One of the residents involved, Resident B, had diagnoses including diabetes, major depressive disorder, chronic kidney disease, and peripheral vascular disease. His bedtime medication orders included carvedilol 25 mg, fenofibrate 145 mg, gabapentin, and oxycodone 10 mg. Instead of these medications, he was administered Tylenol 500 mg two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin, and geodon 60 mg. The following morning, he reported to the DON, with a family member present, that he had received another resident’s medications and stated he felt very tired and sleepy. The other resident, Resident C, had diagnoses including borderline personality, cerebral palsy, anxiety, psychotic disorder, dementia, and muscle weakness, and was severely impaired for daily decision making. He was allergic to haldol and prozac. His bedtime medication orders included Tylenol 500 mg two tablets, baclofen 10 mg, clonazepam 0.5 mg, ferrous sulfate 325 mg, florastor 250 mg, guaifenesin 200 mg, remeron 15 mg, pantoprazole, tamsulosin, and geodon 60 mg. Instead, he was administered carvedilol 25 mg, fenofibrate 145 mg, gabapentin, and oxycodone 10 mg. The DON, Medical Director, and Nurse Practitioner were notified that the residents had received each other’s medications. The facility’s own medication administration policy required verifying a physician’s order, checking the medication label and dose against the MAR, and confirming the resident’s identity, but these steps were not effectively followed, resulting in the medication error.
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