F0760

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Significant Medication Error Leading to Resident Overdose and ICU Admission

Manhattan, Kansas Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure a resident remained free from significant medication errors when a certified medication aide (CMA) administered another resident's medications. The resident had diagnoses including anxiety, coronary artery disease, depression, diabetes mellitus, and functional limitations requiring substantial assistance with activities of daily living. The resident used psychotropic medications for anxiety and depression, and her care plan directed staff to administer medications as needed and to monitor for drug-related complications and changes in depressive or behavioral symptoms.

On the morning of the incident, the resident received her medications from the CMA while seated at a breakfast table next to another resident who shared the same first name and who did take fish oil. The resident later noticed a fish oil capsule in her medication cup, which she did not take as part of her prescribed regimen, and reported to a licensed nurse (LN) that she believed she had received the wrong medications. The LN questioned the CMA, who insisted she had given the correct medications and suggested she might have accidentally added fish oil to the resident's pills. The LN then instructed a certified nurse aide (CNA) to keep an eye on the resident, and the CNA checked the resident approximately 30 minutes later, finding her alert, oriented, and with vital signs within normal limits.

Around an hour after the initial concern, the LN went to the resident's room to provide care and found her lethargic, minimally responsive, and slurring her words. Another LN was called to assist with assessment, and the provider was notified and ordered STAT Narcan and epinephrine, which were administered with minimal response before 911 was called. Emergency medical services were informed of the possible erroneous medication administration, and the resident was transferred to the emergency room, where she was documented as having been accidentally given another resident's medications, including multiple centrally acting psychotropic and other medications. She was diagnosed with a primary unintentional overdose and admitted to the intensive care unit. Later, upon readmission to the facility, the resident reported a gap in memory of the events, expressed fear and distress about not knowing what had happened, and described unsettling dreams, while also recounting that the CMA had appeared distracted and preoccupied with personal issues at the time of the medication pass.

Removal Plan

• Removed CMA R from the medication cart and terminated her employment.
• Evaluated all residents residing on A and B neighborhoods (where CMA R administered meds) for adverse reactions and report any ill effects to their PCP.
• Performed an audit for residents with the same name and placed bright pink "Same Name" labels on the med cards to alert staff.
• Conducted audits of the med cards.
• Re-educated all clinical staff on Same Name Alert, the 5 rights of medication administration, and avoiding distractions during medication administration.