Medication Administration Error Due to Identity Verification Failure
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice by not following physician's orders and ensuring accurate medication administration for a resident. Specifically, a licensed practical nurse (LPN) administered medications intended for another resident to Resident B4. This error occurred because the LPN relied on names and photos on the doorway instead of independently verifying the resident's identity before administering the medications. As a result, Resident B4 received Seroquel, Xanax, and Gabapentin, which were not prescribed for them, leading to increased fatigue. Resident B4 was admitted to the facility with diagnoses including metabolic encephalopathy, pneumonia, and dementia, and was severely cognitively impaired with a BIMS score of 3. The medication error was discovered when the intended recipient, Resident B15, reported not receiving their morning medications. The Director of Nursing confirmed the error and acknowledged the failure to follow professional standards and physician orders during medication administration.
Plan Of Correction
- B4 Assessed with no new recommendations. House audit on current resident completed to determine any medication errors. Policy entitled, "Administering Medications", reviewed for any revisions. Licensed nursing staff re-educated on policy. Medication administration audits completed on all licensed staff to determine competency, along with Narcotic accountability protocol. Random medication administration audits will be completed along with Narcotic accountability for licensed nursing staff weekly x 4, then monthly x 2 by DON or designee. Audits will be presented at the monthly QAPI committee for ongoing oversight.