F0760

J

Significant Medication Error When Wrong Resident Received Another Resident’s Medications

Greer, South Carolina Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration.

The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3.

Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.

Removal Plan

• The Administrator notified the Medical Director of the Immediate Jeopardy.
• R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
• R2 was sent to the emergency department for a higher level of care.
• The Assistant Director of Nursing began the investigation into the medication error.
• The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
• The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
• The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
• The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
• The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
• The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
• The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
• The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
• The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
• Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
• The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.