Significant Medication Error Due to Failure to Identify Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dependent on staff for medication administration, was given medications prescribed for another resident. The medications administered in error included cardiac medications that lower heart rate and blood pressure, an anti-platelet agent, a medication for gout, and an anti-anxiety medication. The error was due to the nurse's failure to properly identify the resident before administering the medications, as confirmed by both the nurse and the facility administrator. The facility's policy required verification of the '5 rights' of medication administration, including ensuring the medication is given to the correct person, but this was not followed. Following the administration of the incorrect medications, the resident experienced a change in condition, including hypotension (low blood pressure), bradycardia (low pulse), and lethargy. The resident was transported to the emergency room, where she was admitted for overnight observation and treated with intravenous fluids. Hospital records confirmed the resident had received multiple medications not prescribed to her, resulting in hypotension and bradycardia throughout her ER stay, which improved with treatment. Medical record review showed that none of the medications given in error were ordered for the resident. The incident was identified before the nurse administered the resident's own medications to another individual. The error was documented in the facility's medication error report, and the nurse involved acknowledged the failure to verify the resident's identity prior to administration. The event affected one of two residents reviewed for medication errors during the survey.
Plan Of Correction
Resident #10 was sent to the ER by the physician on 6/6/25. She returned to the facility on 6/7/25 with no lasting effects of medication error. She was assessed on 6/23/25, 6/30/25, and 7/8/25 by NP since readmit with no ill effects identified. A care conference was held with the family on 6/17/25 with no concerns identified. All residents have the ability to be affected. Therefore, an initial audit was conducted by the DON or designee on 6/6/25 to ensure all residents have appropriate photo identification in the medical record. Any negative findings were addressed immediately. LPN responsible for the error was educated on medication rights to include how to identify a resident on 6/6/25 by the DON. Per policy, a discipline was also issued to the LPN responsible by the DON on 6/6/25 to prevent recurrence. Audits for medication errors were completed by RCS weekly between 6/6/25 and 6/25/25 with no identified errors. All nurses were reeducated by 7/14/25 by the DON or designee on medication pass policy and procedure to include when a nurse is unable to verify resident identification with the medical record picture, they must ask the resident their name and get a response prior to administering the medication. If the resident does not respond, they are to get assistance from other staff members. Medication pass observations of 5 nurses per week for 4 weeks will be conducted by the DON or designee to ensure no significant medication errors occur. Any negative findings will be addressed immediately. The DON is responsible for ongoing compliance. Results of audits will be reviewed at QAPI for adjustments as needed.