Resident Given Another Resident's Medications Due to Identification Failure
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A significant medication error occurred when a resident was administered another resident's evening medications, including 30 units of Lantus, 75 mg of Lyrica, and 5 mg of oxycodone, despite not having physician orders for Lyrica or oxycodone and only being prescribed 10 units of Lantus for diabetes. The error was documented in the nursing notes and confirmed by the Director of Nursing. The resident's medical record indicated that the medications were given along with the resident's usual nightly 4 ounces of scotch. Review of the facility's Medication Pass Policy revealed that staff are required to identify each resident prior to medication administration, but this protocol was not followed, resulting in the medication error.