F0760

G

Wrong-Resident Medication Administration Leading to Hypotension

Phoenix, Arizona Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident received only medications ordered by the provider, resulting in administration of multiple medications that were not prescribed. The resident had diagnoses including hypertension, chronic kidney disease, type 2 diabetes, atrial fibrillation with anticoagulant therapy, and diuretic therapy for fluid overload. The care plan included avoiding aspirin due to anticoagulant therapy and administering diuretics as ordered. Provider orders and the MAR for the relevant period showed active orders for furosemide, spironolactone, calcitriol, and guaifenesin, and no active orders for aspirin 325 mg, carvedilol 6.25 mg, lisinopril 40 mg, or nifedipine ER 90 mg.

On the date of the incident, an LPN entered the resident’s room with medications that were intended for another resident. The LPN later stated that she had used the wrong MAR and entered the wrong room, and that she realized the error only after the resident questioned an enoxaparin injection following administration of the oral medications. The incident note documented that the LPN administered aspirin 325 mg, carvedilol 6.25 mg, lisinopril 40 mg, and nifedipine ER 90 mg instead of the resident’s ordered furosemide 80 mg, spironolactone 25 mg, calcitriol 0.25 mcg, and guaifenesin 600 mg. Interviews with nursing staff confirmed that these medications were not ordered for the resident and that the resident did have orders for the diuretic and other listed medications that were not given at that time.

Following the administration of the wrong medications, the resident experienced low blood pressure readings documented in the blood pressure summary, with systolic readings dropping below 100 mmHg and diastolic readings in the 30s and 40s over the subsequent hours. Staff interviews described that the resident’s blood pressure dropped significantly after the error, that the resident was monitored for hypotension, and that the provider was notified. The resident reported that the nurse did not ask for her name, told her the medications were for high blood pressure, and that she knew something was wrong when the nurse attempted to give an enoxaparin injection, which she did not receive as part of her usual regimen. The resident stated that the wrong medications took about two to three days to clear from her system and that staff had difficulty keeping her blood pressure in a normal range during that time.

Additional documentation from a clinical consultant pharmacist outlined potential adverse reactions associated with carvedilol, lisinopril, nifedipine, and aspirin, including hypotension and bleeding, and indicated that the hypotensive medications would be eliminated from the resident’s system in two to three days. An internal investigation report recorded that the resident had a history of acute chronic diastolic heart failure, hypertension, and high risk for hypotension, and that on the date of the incident the LPN administered medications intended for another resident. The investigation noted that the resident’s creatinine rose to 2.9 with an eGFR of 15. Facility policy on medication administration required staff to follow the rights of medication administration, including right medication and right resident, but interviews and the resident’s account showed that the nurse did not verify the resident’s identity according to policy before administering the medications.