F0760

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Significant Medication Error from Misidentification and Wrong-Resident Opioid Administration

Waterford, Connecticut Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a Schedule III opioid medication (Suboxone 8-2 mg) prescribed for another resident was inadvertently administered to Resident #1. Resident #1 had diagnoses including pulmonary embolism, depression, and difficulty walking, and was care planned for self-care deficits with interventions to administer medications as ordered and monitor for side effects. The five-day MDS showed short- and long-term memory deficits (BIMS score of 7), dependence on staff for toileting, dressing, bed mobility, and transfers, and non-ambulatory status with wheelchair use.

On the evening of 2/5/26, LPN #1, who was administering medications for the first time to Resident #1, was preparing medications for Resident #2 when a family member interrupted and requested that she meet Resident #1 because she was Spanish speaking. After meeting Resident #1, LPN #1 returned to preparing medications for Resident #2 and reported an additional interruption by a nursing assistant. She then entered Resident #1’s room, mistakenly believing this resident was Resident #2 because both residents were Spanish speaking, and began administering medications without verifying the resident’s identity by name or checking the name bracelet. Resident #2 refused all medications except Suboxone, and LPN #1 later realized during shift change that she had administered the Suboxone dose to Resident #1 instead of Resident #2 and had not administered medications to Resident #2.

Following the error, Resident #1 was found with oxygen saturation levels between 83% and 86% on room air, a respiratory rate of 13 (previously 18), heart rate of 92, and pinpoint pupils, while previously normal vital signs had been documented. The APRN, RN supervisor, and DON were notified, and the APRN confirmed that Suboxone was not prescribed for Resident #1, who had never been on opioids, and identified that the dose given was supratherapeutic for an opioid-naïve individual and constituted a significant medication error. Resident #1 required oxygen, Narcan administration, transfer to the ED, and subsequent ICU admission with additional Narcan doses, IV potassium for hypokalemia, IV Diltiazem for hypertension, and continuous telemetry and pulse oximetry monitoring, with a total hospitalization of 11 days. The facility’s Medication Error Policy defined a significant medication error as one resulting in hospitalization, requiring prescription medication to treat the error, or being life-threatening or potentially leading to death, criteria that were met in this incident.

Removal Plan

• Train staff on the five rights of medication administration and perform medication competencies for all licensed nursing staff.
• Provide one-to-one education to the LPN from the consulting pharmacy.
• Conduct random audits of narcotic reconciliation, medication pass observations with licensed staff, change-of-condition documentation, and RN assessments.
• Review audit results at the QAPI meeting.
• Assign the Director of Nursing to implement and monitor the corrective actions with the Administrator maintaining regulatory oversight.