Misappropriation of IV Medication Administered to Wrong Resident
Penalty
Summary
A deficiency occurred when a registered nurse (RN) administered an intravenous (IV) bag of normal saline labeled for a former resident to a current resident. The RN obtained the IV bag from the medication storage room, where it was stored with other extra bags of fluids. The bag was clearly labeled with the former resident's name and a date from several months prior. The RN infused the entire bag into the current resident and later notified the Director of Nursing (DON) about using the bag intended for a different resident. The DON instructed the RN to remove the former resident's name from the bag but was not aware of the date on the bag or that it remained in the resident's room. The facility's Abuse Prevention Policy prohibits the misappropriation of resident property, including the wrongful use of a resident's belongings or medications without consent. In this incident, the RN knowingly used IV fluids prescribed for a former resident and administered them to another resident without proper authorization or consent. The event was confirmed through observation of the labeled empty IV bag in the resident's room, interviews with the resident, RN, and DON, and review of the facility's documentation.