Failure to Verify Patient Identifiers Results in Transfer of Incorrect Medical Records
Penalty
Summary
The facility failed to verify patient identifiers before sending transfer paperwork, resulting in the receiving facility obtaining inaccurate medical records for a resident being discharged. The error occurred when the social services supervisor forwarded discharge paperwork that included a fax cover sheet with the correct resident name but an incorrect date of birth and facility name. The attached medical records belonged to a different individual, and the social services supervisor did not review the details of the paperwork before sending it to the receiving facility. The nurse involved in the transfer provided a verbal report about the resident's mental health status and medications but did not handle the physical paperwork, which was managed by social services. The resident involved had a primary diagnosis of schizoaffective disorder and was prescribed psychotropic medications. Due to the incorrect paperwork, the receiving facility placed orders incorrectly, and the resident did not receive her prescribed medications for approximately two weeks. This lapse in medication administration led to a hospitalization related to her mental health condition. The error was only identified after the receiving facility noticed discrepancies and contacted the advanced registered nurse practitioner (ARNP), who then corrected the orders. Interviews with facility staff revealed a lack of verification processes for transfer paperwork. The social services supervisor admitted to noticing the wrong facility name but did not check other identifiers such as date of birth or the content of the orders. The director of nursing and administrator were unaware of how the incorrect paperwork was included in the resident's electronic health record, and the ARNP confirmed she was not involved with the third facility named on the paperwork. The facility's policy required verification of patient information before disclosure, but this was not followed in this instance.