IDPH has cited and fined Wauconda Care in Wauconda after a resident there had to be hospitalized in the intensive care unit after a medication error in which the the nurse gave medications to the wrong resident.
Many nursing home residents are on multiple medications. One of the basic tasks for members of the nursing staff is to give the medications to the resident as ordered by the doctor.
To safely do this, and avoid nursing home medications errors, nurses are supposed to check the 5 “rights” before giving medications to the resident: (1) is this the right resident, (2) is this the right medication, (3) is this the right dose, (4) is this the right route (pill, oral, etc.), and (5) is this the right time? Checking each of the 5 rights is a simple, but proven and effective way to avoid preventable medication errors.
The resident at issue was in his room with his wife when the nurse came by to administer his medication. The nurse poured all of the medications into the resident’s mouth at the same time, and the resident was unable to swallow the pills or move his mouth at all.
The resident’s wife told the nurse that something seemed wrong but the nurse kept trying to get the resident to swallow his pills and ultimately gave him Glucerna and pudding to aid the effort. The resident’s wife said that two other nurses came into the room and one of them said to call 911 as the resident’s face was drooping like he was having a stroke.
Upon arrival at the hospital the resident’s blood sugar was 17 in the Emergency Room. He was admitted to the Intensive Care Unit where he received intravenous fluids with sugar.
Blood tests for sulfonylurea ultimately revealed the presence of glimepiride, indicating that the resident had been administered the medication for a different resident who was a diabetic.
This was a highly preventable medication error. Giving one resident medications that were intended for another resident is the kind of medication error which should never occur – that is one of the basic “5 rights” that should be verified before giving medication.
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