Failure to Properly Identify Resident Leads to Significant Medication Error
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for one resident to another due to a failure to properly identify the correct resident. The incident took place after two residents decided to switch bed positions, and the facility did not update the bed assignments in the computer system until the following day. As a result, the RN relied solely on room numbers rather than verifying the resident's picture, name, and date of birth, leading to the administration of multiple medications—including insulin, Xanax, atorvastatin, donepezil, duloxetine, Eliquis, acetaminophen, ropinirole, simethicone, and trazodone—to the wrong resident. The RN involved stated that it was his first shift working independently and acknowledged not following proper resident identification protocols, despite having received training. The facility's policies required correct resident identification and medication administration, but these were not followed during the incident. Interviews with facility leadership confirmed awareness of the event and the expectation that residents be properly identified before medication administration. The resident who received the incorrect medications was assessed and found to be in no distress at the time.