Failure to Verify Resident Identity Leads to Administration of Incorrect TPN
Penalty
Summary
A deficiency occurred when a licensed nurse administered total parenteral nutrition (TPN) intended for one resident to a different resident who was also receiving TPN. The nurse failed to verify the resident's identity and did not check the name on the TPN bag before administration, contrary to facility policy. The incident involved a resident with a complex medical history, including hypokalemia, cardiac arrest, hypomagnesemia, tracheostomy, diabetes type 2, ileostomy, and abnormal blood chemistry. The TPN formula administered was not the one ordered for the resident, resulting in vomiting and a low potassium level. Multiple staff statements confirmed that the TPN bag was not checked for the correct patient name, formula, or rate during administration and subsequent shifts. The facility's policy required verification of the resident's identity and the use of a second nurse when administering TPN, but these procedures were not followed. The error was discovered when another staff member noticed the wrong patient's name on the TPN bag during a routine visit to the resident's room.