Significant Medication Error Due to Nurse's Failure to Verify Resident Identity
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a resident who was administered a medication not prescribed by their physician. The resident, who had a medical history including Chronic Hepatitis C, Diabetes Mellitus, and Liver Cirrhosis, was mistakenly given methadone, a narcotic medication, instead of their prescribed medication. This error occurred despite the presence of multiple identification methods, such as an identification band, photo identification, and room label, which were not adequately utilized by the administering nurse. The incident unfolded when a registered nurse, distracted by alarms from a tube feeding pump, administered methadone to the wrong resident. The nurse failed to follow the facility's medication administration policy, which requires verifying the resident's identity and medication details before administration. The nurse did not check the resident's identification band or photo identification and did not confirm the resident's name against the medication label, leading to the administration of methadone to the resident. Upon realizing the error, the nurse reported it to the charge nurse, and the resident was subsequently evaluated by the facility's nurse practitioner. The resident, who was alert and oriented, was transferred to a local hospital for evaluation and observation. The Director of Nursing considered this a significant medication error and initiated an investigation, confirming that all identification and medication labeling protocols were in place but not followed by the nurse.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 F760 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. The nursing staff on unit where resident # 399 resides received education on medication administration, ensuring all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel, Date 2/25/25. Resident # 399 was discharged from facility on 5/8/25, and sent to ER no issues found related to medication error. All residents have the potential to be affected by this practice - Nurse #9 no longer works at the facility - 8 nurses observed during medication pass on 2/25/25. All were noted to follow the policy on verifying the resident and medications. No occurrences found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled medication administration dated 4/20/21 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/designee will educate all nursing staff on medication administration, ensuring all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel. No occurrences found. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/ Designee will perform an Audit for medication administration 5 times per week for random shift to check that all individuals administering medications verifies identity before giving the resident their medication. Methods of identifying the resident include: checking the identification band, checking photograph attached to medical record and if necessary, verifying resident identification with other facility personnel x 3 months. Any discrepancies will be reported to Administrator and immediately corrected, staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.