Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, resulting in the wrong medications being administered to one of three reviewed residents. The facility’s medication administration policy required that only appropriately licensed personnel prepare and administer medications and that the individual administering medications verify the resident’s identity using methods such as checking an identification band, checking a photograph attached to the medical record, and, if necessary, verifying the resident’s identity with other personnel. Despite this policy, an LPN entered a shared room, called out the roommate’s name, and when the resident in the other bed responded and requested assistance, the LPN proceeded to give that resident the medications intended for the roommate. The resident who received the wrong medications had diagnoses including congestive heart failure and paroxysmal atrial fibrillation. Clinical record review showed that the resident was initially assessed after the error and was alert and oriented, with vital signs including a temperature of 97.4°F, BP 105/58, HR 66, and oxygen saturation of 91%. The CRNP was notified of all medications the resident had received in error and instructed that only the resident’s Eliquis be given and all other medications held. When the LPN went to administer Eliquis, the resident was observed to be slightly lethargic, and repeat vital signs showed a BP of 85/50, temperature 98°F, HR 70, RR 15, and oxygen saturation of 92%, with continued lethargy. Further review of the clinical and hospital records revealed that the resident had been given multiple medications not prescribed for them, including aspirin 325 mg, Xcopri 300 mg, Aptiom 800 mg, levetiracetam 1500 mg, lorazepam 1 mg, morphine sulfate 0.25 ml, acetaminophen 650 mg, carbidopa-levodopa 25-100 mg two tablets, and gabapentin 600 mg. Subsequent vital signs showed a BP of 78/52 and increased lethargy, with the resident later unable to state their location. The CRNP ordered Narcan administration and later ordered the resident to be sent to the emergency department for evaluation. Hospital documentation confirmed accidental ingestion of the roommate’s medications, including Ativan (lorazepam), Keppra (levetiracetam), gabapentin, morphine, and Xcopri, with resultant lethargy and hypotension that improved with Narcan, IV fluids, and monitoring.
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