Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a registered nurse administered a set of medications intended for another resident to a resident with multiple chronic conditions, including chronic diastolic heart failure, anxiety disorder, acute respiratory failure with hypoxia, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease. The resident had intact cognition and required staff assistance with activities of daily living. The nurse failed to verify the resident's identity before administering the medications, as required by facility policy, and did not ask the resident's name or attempt any identification. Approximately 20 minutes after the error, the nurse realized the mistake, notified management, and assessed the resident. Following the administration of the incorrect medications, the resident's physician and emergency contact were notified, and the resident was monitored per physician orders. The resident's family requested hospital transfer, and the resident was sent to the hospital, where she presented with altered mental status and was diagnosed with accidental drug overdose and altered mental status. Hospital evaluation included lab work and EKG, which showed no significant abnormalities, and the resident was treated with intravenous fluids and monitored until returning to baseline. The incident was documented in the medical record, medication error report, and hospital records.