Medication Error Due to Misidentification of Resident
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving Resident R1. The error occurred when Resident R1 was mistakenly administered medications intended for her roommate, Resident R2. The medications included amlodipine besylate, furosemide, and potassium chloride, none of which were prescribed to Resident R1. This mistake was documented in Resident R1's progress notes, and both the family and physician were informed. The error was attributed to Registered Nurse Employee E1, who did not realize there were two residents in the room due to a pulled curtain that obstructed her view. Resident R1, who was admitted with diagnoses including influenza, resistant hypertension, and weakness, confirmed the medication error during an interview. Although she reported being fine afterward, she described the event as "scary." The Nursing Home Administrator and Director of Nursing acknowledged the facility's failure to prevent significant medication errors. The incident highlights a lapse in following the facility's medication administration policy, which mandates adherence to the six rights of medication administration to prevent such errors.
Plan Of Correction
R1 suffered no adverse effect from receiving R2's meds for 1 dose. R1 was offered counseling services. Personal Care Medical Associates and family were immediately notified. Reportable was completed on 2-2-25 on the ERS system. Whole house audit completed to ensure no other residents received incorrect medication. Education on medication administration provided to nurses by DON or designee on or before 2/17/2025. Audits will be conducted on medication passes on 4 nurses weekly by NHA or designee weekly x 4 weeks and monthly x 1 month.