Significant Medication Errors Due to Incorrect Dosing and Resident Misidentification
Penalty
Summary
The facility failed to prevent significant medication errors for two residents. In one instance, a resident received 2 mg of Clonazepam instead of the ordered 1 mg dose. The error was discovered during a medication count at shift change, and documentation showed that the medication order had been revised to specify only one tablet should be given. The resident's progress notes indicated a change of condition following the administration of the incorrect dose, and the error was confirmed through review of the medication administration record and staff statements. In another case, a resident was administered 4 units of Lispro insulin due to the nurse misidentifying the resident by picture and name. The error was documented in the resident's progress notes, which indicated that the resident remained stable with no signs of hypoglycemia or hyperglycemia following the incident. The incident report confirmed that the LPN did not properly identify the correct resident before administering the medication.