Failure to Verify Resident Identity and Match Prescription Labels with Physician Orders During Medication Administration
Penalty
Summary
The facility failed to ensure safe and accurate medication administration for four residents by not properly verifying resident identity and by not ensuring that prescription labels matched physician orders with specific administration parameters. During medication passes, two licensed vocational nurses (LVNs) administered medications to two residents without using appropriate identifiers to confirm their identities. In both cases, the nurses either called the resident by name or responded to a resident's request for medication but did not check identification bracelets or ask the residents to state their names, as required by facility policy. Both residents confirmed that their identities were not verified prior to receiving their medications. Additionally, the facility did not ensure that prescription labels for two other residents matched the physician orders, which included specific parameters for holding blood pressure or heart rate medications. For one resident, the physician's order for Spironolactone included instructions to hold the medication if the systolic blood pressure was below 110 mmHg or the heart rate was below 60 bpm, but the prescription label did not reflect these parameters. Similarly, another resident's order for Amiodarone included a hold parameter for heart rate below 60 bpm, which was also missing from the prescription label. In both cases, the nurses acknowledged the discrepancies between the physician orders, the medication administration record (MAR), and the prescription labels. The facility's policy and procedures require verification of resident identity before medication administration and mandate that the prescription label, physician order, and MAR must match, with any discrepancies resolved prior to administration. The Director of Nursing confirmed that these steps are necessary to prevent medication errors and ensure safe medication practices. However, observations and interviews revealed that these procedures were not consistently followed, resulting in the identified deficiencies.