PUEBLO, CO- ROCK CANYON RESPIRATORY

The facility failed to ensure the residents were kept free from significant medication errors…

Specifically, the facility failed to ensure a registered nurse (RN) #1 correctly transcribed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #1 on 5/18/22, and several hours after the administration of the medication the resident became unresponsive while away from the facility and was transported to a local hospital.

The facility investigation determined RN #1 had entered the order so that both doses (75 mg and 100 mg) started on the same day, therefore the resident was given 175 mg of [MEDICATION(S)] on 5/18/22 instead of the physician ordered 75 mg.

The DON was interviewed on 6/27/22 at 1:19 p.m. She said the facility became aware of the medication error the day of the order due to the resident being sent to the hospital directly from an appointment with her provider. The DON said it was determined RN #1 had made a transcription error, and due to that error the resident received more than double her prescribed dose of [MEDICATION(S)].

A review of the hospital records from 5/18/22 revealed the following ICU (intensive care unit) progress note: This is a (age) woman with a history of [CONDITION(S)] and depression who presents from her (name of facility) after being found unresponsive. Unable to obtain any history from the patient as she is unresponsive. Per report from someone at the facility, the patient likely received double her dose of [MEDICATION(S)].