Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a nurse administered a set of medications intended for one resident to another resident with severe cognitive impairment. The resident who received the incorrect medications was unable to identify themselves and had no physician's orders for any of the medications given. The medications administered included multiple drugs such as an antidepressant, anticoagulant, antipsychotic, nitrates, proton pump inhibitor, laxatives, cardiac glycoside, antihypertensives, and others. The nurse failed to verify the resident's identity using the facility's established procedures and did not check the resident's photo or confirm with another staff member prior to administration. The nurse involved was working on the dementia unit for the first time and was unfamiliar with the residents. She prepared the medications for one resident, entered the shared room, and found only one person present. Believing there was only one resident in the room, she addressed the resident by the intended recipient's name. The resident, who was severely cognitively impaired, nodded in response, and the nurse proceeded to administer the medications. It was only after a CNA entered the room and addressed the resident by a different name that the nurse realized the error. Interviews with facility leadership and staff confirmed that the nurse did not follow the five rights of medication administration and did not positively identify the resident before giving the medications. The resident who received the incorrect medications required transfer to the hospital for evaluation and treatment, including monitoring and intravenous therapy, due to the effects of the medication error. The facility's policies on medication administration and error prevention were not followed during this incident.