An agency LPN administered another resident’s medications to a resident with dementia and dysphagia, including Amlodipine 10 mg, Aspirin, Divalproex Na, Zoloft, and Iron, in addition to the resident’s ordered Amlodipine 2.5 mg. The resident had moderately impaired cognition and was later sent to the ER for observation after a blood pressure drop was documented. The error occurred when the LPN failed to correctly identify the resident during med pass.
An LPN failed to properly identify a resident before giving medication, and one resident received methadone ordered for another resident. The resident who received the dose had dementia and a moderately impaired BIMS score, while the intended recipient had an opioid-related history and an active methadone order. After the error, Narcan was given and the resident was sent to the ED, where the resident was noted to be very sleepy.
A resident with multiple complex conditions and g-tube dependence experienced several medication administration errors by an LPN during a medication pass. The LPN gave aspirin with an unreadable expiration date, failed to administer ordered thiamine and lactulose due to unavailability in the cart, did not assess bowel status or give Miralax as intended, and administered a steroid nebulizer before a bronchodilator. The LPN also delivered only 330 ml instead of the ordered 360 ml of Glucerna 1.5 via g-tube and removed a scopolamine patch applied the previous day without verifying the order or replacing it, despite an active 72-hour order. These actions did not follow physician orders or facility medication and enteral feeding policies.
An orientee LPN, while paired with preceptors, twice failed to verify resident identity and administered medications prescribed for one resident to another. In one shared room, a cognitively intact resident stated the roommate’s name, and the LPN did not check the ID band, resulting in administration of diabetes, reflux, and mood-stabilizing meds intended for the roommate. On another occasion, the LPN was told to give meds to a specific roommate but instead gave a regimen including Jardiance, Metoprolol, Protonix, PreserVision, and Eliquis to the wrong roommate, who had different active orders and later developed hypotension and hypoxia requiring hospital admission. Facility policy required verification of the “five rights” and prohibited giving one resident’s meds to another, yet the orientee was allowed to pass meds independently, and the orientation checklist for the LPN was blank.
A resident with DM2, cirrhosis with ascites, depression, and hepatic encephalopathy had multiple meds, including insulin, diuretics, lactulose, and antidepressants, administered late on repeated occasions. The MAR audit showed several doses given well outside the ordered times, including pre-meal insulin and bedtime meds, and there was no progress note documentation explaining the delays. An LPN stated meds should be given within one hour of the scheduled time and could not explain the late administrations; the DON also stated the delays were not acceptable.
A resident with ESRD, HTN, and DM had medication administration errors involving insulin and Midodrine. The eMAR showed NovoLOG was given when blood glucose was below the ordered hold parameter, and Midodrine was withheld when BP was within range and given when BP was above the ordered hold parameter. An LPN/UM confirmed the MAR entries reflected administration and acknowledged the doses did not follow the PO parameters.
A resident with multiple medical conditions was admitted and had medications reconciled by an LPN/UM who failed to verify that all pages of a multi-page medication list belonged to the correct individual, resulting in transcription of another resident’s psychotropic and cardiac medications into the new admission’s EMR and MAR. These incorrect medications, including furosemide, lithium ER, trazodone, clonazepam, and risperidone, were then administered over several days until the resident’s representative questioned the accuracy of the list and reported that the resident was not completing sentences. Review of records and staff interviews confirmed that the medications actually belonged to another resident and that the provider had been given inaccurate information when admission orders were obtained.
A resident with hypotension, hemiplegia, hemiparesis, and chronic atrial fibrillation had a Midodrine order to hold if systolic BP was over 110. The eMAR showed the med documented as given when BP readings were above the hold parameter, and staff interviews confirmed that the check mark meant administered and that the order should not have been followed that way.
A resident with hypotension received Midodrine outside the ordered blood pressure parameters, and the eMAR also showed multiple withheld doses documented with an X instead of an actual BP reading. In a separate med pass, an RN gave insulin aspart after the meal using a blood sugar result that was about two hours old instead of a current reading, despite the order requiring scheduled pre-meal administration and dosing based on the current BS.
An LPN administered IV antibiotics to two residents in error, giving each the other's prescribed medication due to failure to follow medication administration protocols, including the 5 Rights and required checks. One resident experienced an adverse drug reaction and required hospital admission, while the other was monitored without incident. The error was discovered after the infusions were completed, with staff noting that medication bags were clearly labeled but not properly verified before administration.
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