Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN), identified as an agency nurse, administered another resident's medications to a resident with a history of Chronic Obstructive Pulmonary Disease (COPD) and Type 2 Diabetes Mellitus. The facility's policy required staff to verify the resident's identity before administering medications, but this protocol was not followed. The error was discovered after a Certified Nurse Aide (CNA) found a medication cup labeled with another resident's name in the affected resident's trash can. The resident subsequently exhibited a change in mental status, including drowsiness and unresponsiveness, which was reported to the Registered Nurse (RN) and led to further assessment and intervention. The resident was transferred to the emergency room for evaluation and received treatment including intravenous fluids, potassium replacement, and oxygen therapy. Documentation confirmed that the medications administered matched those prescribed to another resident, which included several medications for epilepsy and pain management. Interviews with facility staff, including the DON and Administrator, confirmed that the LPN failed to follow the five rights of medication administration, resulting in a significant medication error that required hospital evaluation and overnight observation for the resident.