F0760

J

Significant Medication Error During Training Medication Pass

West Kingston, Rhode Island Survey Completed on 02-18-2026

Penalty

Fine: $21,645

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident was inadvertently administered multiple medications prescribed for a roommate. The facility’s Medication Administration Safety Program policy required that the same person who prepares medications must administer them and that the licensed staff member must confirm the resident’s identity prior to administration. On the date of the incident, RN Staff A was training newly hired LPN Staff B during the morning medication pass and prepared a set of medications at the cart for Resident ID #2, including two antihypertensives, an antidiabetic, an antiplatelet, an antiparkinsonian agent, an antidepressant, a multivitamin, and two additional vitamins.

Resident ID #1 had been admitted in January 2026 with diagnoses including orthostatic hypotension, autonomic nervous system disorder, and thrombocytopenia. Resident ID #2 had been admitted in July 2025 with diagnoses including Parkinson’s disease, diabetes mellitus, high blood pressure, major depressive disorder, and coronary artery disease. After RN Staff A prepared Resident ID #2’s medications and handed them to LPN Staff B with instructions to administer them to Resident ID #2, Staff B went into the shared room, identified both residents, but proceeded to administer the medications intended for Resident ID #2 to Resident ID #1 instead. Staff B then returned to the medication cart, where RN Staff A had prepared Resident ID #1’s medications, and both staff re-entered the room to administer those medications.

At that time, LPN Staff B informed RN Staff A that Resident ID #1 had already received the medications intended for Resident ID #2. Subsequent nursing documentation showed that immediately after the error was identified, Resident ID #1’s blood pressure was 99/61, and later readings declined to 78/40 and then 63/37, with the resident becoming pale and weak. The resident’s condition required transfer to the hospital, where continuity of care documentation indicated arrival to the emergency department with hypotension, dizziness, and lightheadedness, and the need for IV fluid boluses for systolic blood pressure readings in the 80s. The DON acknowledged during interview that Resident ID #1 inadvertently received Resident ID #2’s medications and was admitted to the hospital with hypotension as a result.