F0658

D

Medication Administration Errors Involving Wrong Resident and Incorrect Lyrica Dose

Boone, North Carolina Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves failures to ensure medications were administered as prescribed, resulting in two separate medication errors. In the first incident, a nurse administered Adderall XR 20 mg that was prescribed for one resident to another resident with a very similar name. The nurse reported that she was interrupted by another staff member during the morning medication pass, inadvertently entered the wrong room, and gave the medications to the wrong resident. The resident who received the Adderall noticed that there were more pills than usual and stated that they did not look like his pills, but he had already taken the Adderall capsule by the time the nurse attempted to stop him.

The resident who received the wrong medication had diagnoses including urinary retention, metabolic encephalopathy, and hypertension, and his cognition was documented as severely impaired. The Adderall XR 10 mg capsules, two by mouth in the morning, were ordered for a different resident with ADHD and moderately impaired cognition. The error was discovered when the nurse compared the remaining pills to the intended resident’s Medication Administration Record and medication cards and determined that Adderall had been given to the wrong resident. The nurse then reported the medication error to the unit manager.

In the second incident, another nurse administered an incorrect dose of Lyrica to a resident with diabetes mellitus and neuropathy. The resident had physician orders for Lyrica 25 mg once daily and Lyrica 50 mg at bedtime. Review of the declining count sheet for the 50 mg capsules showed that two 50 mg capsules were removed at a single bedtime administration, resulting in a 100 mg dose instead of the prescribed 50 mg. The error was discovered the following morning by a different nurse when she attempted to administer the morning 25 mg dose, found no 25 mg capsules or count sheet, and noted that two 50 mg capsules had been signed out the previous night. The resident, whose cognition was moderately impaired, was described as drowsy in the morning, which staff stated was not unusual for him, and he was later assessed and monitored after the error was reported.

The nurse who made the Lyrica error did not provide a statement, as multiple attempts to contact her were unsuccessful. Facility staff, including the weekend supervisor, unit manager, DON, and NP, confirmed that the resident had received a double dose of Lyrica 50 mg at bedtime instead of the ordered single 50 mg dose. The NP documented that the resident had accidentally received a higher dose of Lyrica than prescribed and that he was awake, alert, and interacting with family at the time of assessment. Both incidents demonstrate that medications were not administered in accordance with the physician’s orders, leading to residents receiving either another resident’s medication or an incorrect dosage of their own medication.