IDPH has cited and fined Manor Court of Freeport nursing home after a resident there received the medications which were to be given to another resident resulting in an admission to the intensive care unit.
Dispensing medications is one of the basics tasks that a nurse in a nursing home does on a regular basis. Given the number of residents that they are caring for and the number of medications that each receives, it is a task that carries a high risk of error and the potential for disaster given the medically fragile condition of most nursing home residents. to prevent medication errors, nurses are supposed to follow the five “rights” in administering medications: right patient, right medication, right dose, right time, and right route. Not getting all five “rights” just right can result in a critical nursing home medication error.
When nurses are preparing their medication trays, attention to detail is required. If they become distracted or fail to give the task their full attention, they can very easily lose track of what they are doing and one or more of the five “rights” can be missed. That was the case here.
While the nurse assigned to the resident at issue was preparing medications for the patient assigned to her, the resident began to get up from the table unassisted. The nurse saw this and went to help her, but when she returned to her task of preparing the medications, she lost track of what she was doing and ended up giving the resident at issue not only her own medications, but also the medications that were ordered for another resident. This resulted in the resident not only receiving her own dose of Lasix (a diuretic or “water pill”), but also another resident’s dosage of Lasix, plus two blood pressure medications and and two diabetes medications which she did not need at all.
Fortunately, the nurse recognized the error shortly after the error occurred and she was sent to the hospital where she was admitted to the intensive care unit.
The resident’s daughter reported to the state inspector and the doctors at the hospital that this was not the first time that her mother had been the victim of a medication error. The Director of Nursing told the state inspector that the nurse involved had been written up and then transferred out of the dementia unit due to the fact that this was not the first time that this nurse had made a medication error due to becoming distracted during medication pass. She was instead sent to a unit with non-dementia patients who should be able to recognize when they are being given wrong medications in the event that the nurse made an error in dispensing medications.
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