F0760

J

Fatal Medication Error Due to Failure to Correctly Identify Resident

Owasso, Oklahoma Survey Completed on 03-13-2026

Penalty

Fine: $22,925

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically failing to correctly identify a resident before administering medications. A cognitively impaired resident with a history of atherosclerotic heart disease, hyperlipidemia, hypertension, and traumatic brain injury was admitted with orders that included amlodipine 5 mg for hypertension, to be held if systolic blood pressure was less than 115 or heart rate was less than 50. A quarterly assessment documented significantly impaired cognition with a brief mental illness score of 03, use of multiple psychotropic and other medications, and no indication that the resident rejected care. Vital signs taken the morning of the incident showed a blood pressure of 147/76 and pulse of 83 beats per minute.

On the morning in question, a CMA administered medications intended for the resident’s roommate to this resident after asking the resident if they were the roommate and accepting the resident’s incorrect verbal confirmation as sufficient identification. The CMA reported being unfamiliar with the residents and relied on the resident’s verbal response rather than using other identification methods such as the photo in the health record, despite the resident’s known cognitive and hearing impairments. As a result, the resident did not receive 11 medications that were prescribed for them and instead received multiple medications prescribed for the roommate, including amlodipine 10 mg, lisinopril 40 mg, and labetalol 300 mg, all ordered with parameters to hold for low systolic blood pressure and/or low heart rate.

Shortly after the medication error, nursing notes documented that the resident became diaphoretic, lethargic, pale, cyanotic around the lips, with labored breathing and unresponsiveness. EMS records indicated the facility reported that the resident had been given amlodipine, aldactone, aspirin, baclofen, cyanocobalamin, fluoxetine, glimepiride, labetalol, lamotrigine, lisinopril, metformin, and potassium chloride in error, and EMS found the resident lethargic with sinus bradycardia, shallow respirations, and initiated cardiac arrest protocol. Hospital records showed the resident was treated for having been administered the wrong medications and was diagnosed with hypotension, bradycardia, and asystole, and was pronounced expired later that morning. The medical director stated that labetalol 300 mg administered in error could have caused the resident to expire and that labetalol, amlodipine, and lisinopril all lower blood pressure, and further noted that epinephrine administered by EMS in the presence of labetalol could have caused an acute cardiac event. The resident’s representative stated the resident expired as a result of the medication administration error.