Failure to Reconcile Discharge Medications Results in Medication Error
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to properly cross-check and reconcile discharge medications according to facility policy, resulting in the transfer of two medications—Atorvastatin and Eliquis—prescribed for one resident to the caregiver of another resident who was not prescribed these medications. The error occurred during the discharge process, when the LVN inadvertently provided two medication carts belonging to the first resident to the caregiver of the second resident. The facility’s policy required nurses to reconcile all pre-discharge medications with the resident’s post-discharge medications and document the reconciliation, but this step was not completed. The resident who was supposed to receive the medications had a history of hypertensive heart disease with heart failure and no mental impairment, while the resident who mistakenly received the medications had diagnoses of encephalopathy and cirrhosis of the liver, with moderate cognitive impairment. The error was discovered after the family of the second resident reported receiving medications not prescribed to their family member, prompting notification of facility leadership. Review of medical records confirmed that the medications in question were not prescribed to the second resident, but were prescribed to the first.