F0760

J

Significant Medication Error from Pre-Poured and Misadministered Drugs

Orchard Park, New York Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an LPN pre-poured and misadministered medications. Facility policy on medication administration required staff to identify the resident, compare the medication label to the medication administration record, prepare and administer ordered medications to the correct resident, and document administration. Despite this, on the evening of 02/23/2026, LPN #1 pre-poured medications for approximately 20 residents for the entire shift into plastic cups labeled with resident names, contrary to expectations not to pre-pour. During administration, LPN #1 misidentified pregabalin, believing it matched a medication ordered for Resident #1, and administered a full cup of medications intended for Resident #2 to Resident #1.

Resident #1 had diagnoses including Parkinson’s disease, dementia, and anxiety, and received multiple psychotropic and anticoagulant medications as part of their usual regimen. The resident’s care plan directed staff to administer medications per provider orders and monitor for adverse reactions and effectiveness. After the wrong medications were given, documentation by LPN #1 at 9:09 PM on 02/23/2026 noted that another resident’s medications had been administered and that the nursing supervisor, physician, and family were notified, with vital signs reportedly stable at that time. However, the Weights and Vitals Summary at 12:05 AM on 02/24/2026 showed a blood pressure of 90/52 and heart rate of 52, with no corresponding nursing notes or additional vital signs documenting assessment of these changes or any change in mental status, and there was no documented evidence that the physician was notified of these findings.

Subsequently, in the early morning hours of 02/24/2026, LPN #2 documented that Resident #1 was difficult to arouse, responded minimally to sternal rub, had a blood pressure of 85/50, and had extended periods between respirations. A follow-up note recorded that only a level 3 voicemail (non-urgent, no return call necessary) was left for the physician. RN Supervisor #2 documented the resident was lethargic but responsive to verbal and tactile stimuli, with blood pressure 85/50, pulse 50, and respirations 10 with pauses between breaths followed by heavy breaths. When the physician evaluated the resident later that morning for an acute visit related to the medication error, the resident was sleeping, not following commands, and had a respiratory rate of 10; Narcan was ordered and administered. Interviews with the pharmacy consultant, DON, attending physician, and medical director confirmed that nurses were expected to follow the six rights of medication administration and not pre-pour medications, and that the medications erroneously given were potent agents capable of causing lethargy, decreased blood pressure, decreased respirations, and altered mental status.