Failure to Properly Identify Resident Leads to Medication Error and Hospitalization
Penalty
Summary
A medication error occurred when a Certified Nurse's Assistant - Medication Aide (CNA-M) administered medications intended for one resident to another resident. The CNA-M retrieved medication cards from a slot labeled for a specific room and bed, prepared the medications, and asked the resident in that room if they were the name on the medication card. The resident confirmed, and the medications were administered. Upon returning to the medication cart, the CNA-M realized the error and immediately notified the nurse. The CNA-M admitted to not verifying the resident's identity using the required two identifiers, such as the identification bracelet and photograph, as outlined in facility policy. The resident who received the incorrect medications was subsequently assessed and initially found to be stable, but was later transferred to the hospital for abnormal vital signs. The medications administered included several antihypertensive agents and other drugs, which led to a hypotensive episode requiring admission to the critical care unit for monitoring and treatment. Facility policy requires the use of at least two resident identifiers before medication administration, and specifically prohibits using room number or physical location as an identifier. The failure to follow these procedures directly resulted in the medication error and the resident's hospitalization.