F0760

J

Significant Medication Error and Delayed Response After Wrong Medications Given

Athens, Ohio Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to ensure that a resident was free from significant medication errors when an agency LPN did not follow proper medication administration procedures. The LPN prepared and administered evening/bedtime medications for two roommates at the same time, in a dark room, by popping both residents’ pills into separate cups labeled with their names. The LPN later admitted that she prepared both residents’ medications together and that the room was dark when she administered the medications. One resident, who was not ordered any benzodiazepines or opioid pain medications, was instead given medications that were ordered for his roommate, including Xanax 2 mg PO, Percocet (Oxycodone/Acetaminophen) 10–325 mg PO, and Gabapentin 800 mg PO.

The resident who received the wrong medications had a history that included dementia with Lewy Bodies, neurocognitive disorder, mood disorder, major depressive disorder, anxiety disorder, CHF, hypertension, cirrhosis, muscle weakness, difficulty walking, and insomnia. His active orders included medications such as Abilify, Aspirin, Atorvastatin, Vitamin D, Plavix, Aricept, Fluoxetine, Lactulose, Magnesium Oxide, Melatonin, Remeron, Potassium Chloride, Sennosides, and Tamsulosin, with PRN orders for Acetaminophen, artificial tears, Mucinex, and Zofran. He had no orders for benzodiazepines or opioids. On the evening in question, the LPN documented administering his scheduled evening/bedtime medications around 8:44 P.M. and noted that he complained of being tired after a room change earlier that day. Shortly thereafter, his roommate complained to a CNA that his pain medications did not feel like they had worked, stating he could usually tell within 10 minutes when they took effect, suggesting concern that he had not received his usual medications.

The facility also failed to timely identify and correlate the reported medication mix-up with the resident’s subsequent change in condition. Around 8:53 P.M., the LPN found the resident lethargic but responsive to touch and able to follow simple commands, with vital signs within acceptable ranges. The resident’s wife reported that he had not awakened during her visit. Despite the roommate’s report that he believed the medications had been mixed up and the LPN’s own acknowledgment that both residents’ medications had been prepared together, the LPN did not notify a physician of a possible medication error or seek medical guidance at that time. Throughout the night, the resident remained lethargic, and staff noted that something seemed “off,” but no provider was contacted until approximately 1:15 A.M., when the resident was found unresponsive, hypotensive, and bradycardic. EMS was then called, and the resident was transferred to the hospital with an altered mental status and unresponsiveness. Hospital evaluation, including a urine drug screen, showed the presence of benzodiazepines and oxycodone, which matched medications ordered for the roommate and not for the resident, confirming that a significant medication error had occurred and contributed to the resident’s serious deterioration in condition.

Additional documentation from EMS and the hospital further described the resident’s condition following the error. EMS records indicated that the resident was unresponsive with pinpoint pupils, hypotension, bradycardia, and a Glasgow Coma Scale score of seven, and he received multiple doses of Narcan and Atropine en route. The ED provider note documented hypotension, bradycardia, poor responsiveness, and initial miotic pupils with partial response to Narcan, and the clinical impression included acute encephalopathy and unresponsiveness. The hospital history and physical described acute hypoxic respiratory failure and multifocal pneumonia, with progressive respiratory decline requiring endotracheal intubation and ICU admission. These findings, together with the positive urine drug screen for benzodiazepines and oxycodone in a resident without orders for those medications, were included in the facility’s investigation file as evidence of the significant medication error and its impact on the resident’s condition.

The facility’s internal investigation gathered statements from the involved LPN, another LPN who assessed the resident, and a CNA. The agency LPN confirmed that she had prepared both roommates’ medications at the same time, in the dark, and that the roommate later complained that his medications did not feel effective. The second LPN reported that the resident’s condition appeared abnormal and that she eventually insisted he be sent out when he no longer responded as before. The CNA reported that the resident initially seemed at his baseline but later became more lethargic and took a “drastic turn” after his wife left. The DON acknowledged that the incident was possibly medication-related and that the resident’s transfer to the hospital for unresponsiveness was logged as an incident. Collectively, these actions and inactions—improper preparation and administration of medications, failure to promptly recognize and act on the reported medication mix-up, and delayed notification of a physician despite progressive lethargy—constituted the deficiency in ensuring the resident was free from significant medication errors.