Medication Errors During Orientation Lead to Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, affecting two residents with severe cognitive impairment. One resident, admitted with seizure disorder, disorganized schizophrenia, and anxiety, had an MDS showing severe cognitive impairment. On the evening of 11/14/25, this resident was administered Ativan 1 mg, Metformin 500 mg, and Remeron 7.5 mg by LPN #188, despite having no orders for these medications. Another resident, admitted with dementia, type 2 diabetes mellitus, and schizoaffective disorder, also had an MDS indicating severe cognitive impairment. On the same evening, this resident was administered Lithium 750 mg, Lamictal 150 mg, Clozapine 300 mg, atorvastatin 20 mg, and Risperdal 1 mg, none of which were ordered for this resident. Following the incorrect medication administration, the second resident was found unresponsive later that night and was transferred to the hospital, where documentation showed admission for a complicated urinary tract infection. The facility’s medication error investigation determined that LPN #188 had administered medications prescribed for the second resident to the first resident and medications prescribed for the first resident to the second resident, after confusing the two residents who shared a room. At the time of the incident, LPN #188 was in orientation with RN #151. RN #151 reported that she instructed LPN #188 to administer medications and remained on the unit and available for questions but did not accompany him into the room during the medication pass. The facility’s medication administration policy required adherence to the six rights of medication administration and verification of the correct resident by comparing the medication source with the MAR prior to administration, which was not followed in this incident.
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