Failure to Verify Resident Identity Leads to Significant Medication Error
Penalty
Summary
The facility failed to verify the correct identity of a newly admitted resident, resulting in the entry of incorrect medication orders into the Electronic Health Record (EHR). Admission paperwork received by the Director of Admissions and Marketing contained information for a different resident with the same name but a different date of birth. This error was not identified during the medication reconciliation process, and the orders were entered into the EHR without confirming the six rights of medication administration. As a result, the resident did not receive her prescribed antipsychotic medications for approximately two weeks following admission. During this period, the resident, who had a history of schizoaffective disorder, hypothyroidism, and other chronic conditions, exhibited significant changes in behavior and mental status. Progress notes documented medication refusals, emotional distress, agitation, and statements indicating psychosis and withdrawal symptoms. The resident's family noticed a decline and questioned whether the correct medications were being administered. It was later confirmed by the DON that the orders entered were not for the correct resident, and the error was only identified after the family raised concerns. The lack of proper verification and reconciliation led to the resident experiencing exacerbation of psychosis, agitation, and withdrawal symptoms, ultimately resulting in hospitalization. Upon return from the hospital, the resident had developed a stage 3 sacral pressure ulcer. Interviews with staff revealed that the process for verifying resident identity and medication orders was not consistently followed, and the policy for medication reconciliation was not adequately implemented, contributing to the significant medication error and subsequent harm to the resident.