F0760

G

Significant Medication Error and Multiple Medication-Pass Failures

Austin, Minnesota Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by not adhering to the rights of medication administration. One resident with diagnoses including heart failure, transient cerebral ischemic attacks, renal insufficiency/failure, and use of anticoagulants was inadvertently given another resident’s full set of morning medications by a trained medication aide (TMA) who was agency staff and unfamiliar with the resident. The TMA prepared medications for the intended resident, verified that resident’s picture and room number in the EHR, but then entered the wrong room and did not verify the room number or the resident’s identity before administering the medications. The TMA administered multiple medications not prescribed to this resident, including antihypertensives, diuretics, antiplatelet, antidepressant, anticonvulsant/mood stabilizer, diabetic medication, and others, and only realized the error when attempting to give an inhaler that the resident stated she did not take.

Following administration of the wrong medications, the resident initially had stable vital signs but later became unresponsive, with no response to verbal commands and only a grimace to sternal rub, prompting transfer to the emergency department. Hospital documentation identified accidental drug ingestion, hypotension secondary to accidental drug ingestion, blurry vision, orthostatic hypotension, and an acute kidney injury with elevated creatinine. The resident experienced symptomatic orthostatic hypotension with dizziness and blurry vision on standing and required interventions such as compression wraps, abdominal binder, hydration, and titration of midodrine. The medical director considered this a significant medication error and stated that the resident’s hypotension and acute kidney injury were likely caused by receiving medications not prescribed to her.

Additional deficiencies were identified in the facility’s medication administration practices for other residents. One resident with heart failure and GERD was observed during a medication pass when an RN misread an order for an oral antifungal as “swish and spit” instead of the ordered “swish and swallow,” and the RN acknowledged this as a medication error. Another resident with heart failure, Parkinson’s disease, dementia, and hospice services had an order for scheduled lorazepam 1 mg three times daily; this resident received an extra dose of lorazepam when a TMA assumed there was an as-needed order and did not verify the physician’s orders before administering the additional dose. Multiple staff interviews revealed that TMAs and an RN had incomplete or unclear understanding of the rights of medication administration, and that medication pass audits and competencies had been conducted by an administrator who was not a licensed nurse and had no formal training in medication administration, as well as by LPNs, contrary to the DON’s statement that such competencies should have been done by an RN. The facility’s own policy required verification of resident identity and triple-checking the label for right resident, medication, dosage, time, and route, which was not followed in these instances.

The facility’s failure to ensure that staff consistently followed the rights of medication administration, verified resident identity, and accurately read and followed physician orders led to a significant medication error causing actual harm to one resident and additional medication errors for two other residents. Staff interviews confirmed lapses in performing the required checks and in understanding all components of the rights of medication administration, despite recent audits and competencies. The documented events show that the facility did not effectively implement its own medication administration policy, resulting in residents receiving medications that were incorrect in recipient, route, or dose.