Failure to Verify Resident Identity Results in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a nurse administered medications to the wrong resident. The facility's policy required staff to verify resident identity using methods such as checking identification bands, photographs, or confirming with other personnel before administering medications. However, a Licensed Practical Nurse (LPN) who was unfamiliar with the unit and the residents failed to verify the identity of a resident before giving medications. As a result, the resident received multiple medications, including Keppra, Remeron, Lyrica, Trazodone, and Warfarin, which were not prescribed to him but were intended for his roommate. The resident was not scheduled to receive any nighttime medications at that time and did not have diagnoses requiring those medications. The affected resident had a history of hypertension, muscle weakness, and moderately impaired cognition, as indicated by a BIMS score of 11. After receiving the incorrect medications, the resident's blood pressure was recorded as low, and the physician was notified. The resident was sent to the emergency room for evaluation due to the medication error and a recent unwitnessed fall earlier that day. Upon return from the hospital, the resident was noted to be lethargic. Interviews with facility leadership confirmed that the LPN failed to follow proper identification procedures, resulting in the administration of another resident's medications.