Medication Administration Errors Involving Wrong-Resident Dosing
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders, resulting in residents receiving medications prescribed for other residents. In the first incident, a cognitively intact resident with diagnoses including diabetes mellitus, hypertension, constipation, restless leg syndrome, hallucinations, and major depressive disorder was given his roommate’s medications during a bedtime medication pass. The medications administered in error included melatonin, sennosides, tizanidine, trazodone, carvedilol, and metformin, all of which were ordered for the roommate. The error occurred when the nurse assigned to both residents’ section pulled the roommate’s medications and mistakenly administered them to the wrong resident. The circumstances leading to this first error included the nurse’s failure to follow basic medication administration protocols. The DON later explained that the agency nurse did not check the five rights of medication administration before giving the medications. The resident was his own responsible party and was informed of the error, and the on-call provider was notified. The Medical Director later stated that the roommate was not on anything that could harm the resident and that the resident was prescribed some of the same medications he received in error. However, the deficiency centers on the nurse’s incorrect selection and administration of medications intended for another resident during the medication pass. In the second incident, another cognitively intact resident with diagnoses including end stage renal disease on dialysis, coronary artery disease, hypertension, diabetes mellitus type II, and COPD received medications that were not prescribed for him during a 2:00 PM medication pass. This resident had no medications ordered at that time, but was given acetaminophen 325 mg (three tablets) and buspirone 7.5 mg (one tablet), which were ordered for a different resident with spastic hemiplegia following stroke, diabetes mellitus type II, and chronic pain syndrome. The error was discovered when the resident’s family member questioned the administration of medications at a time the resident did not usually receive them. Review of the MARs by facility staff confirmed that the agency nurse had administered another resident’s scheduled 2:00 PM medications to this resident, constituting a second medication administration error arising from failure to ensure that medications were given only to the residents for whom they were prescribed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.