Medication Administration Error Due to Failure to Verify Resident and Medications
Penalty
Summary
A certified medication aide (CMA) was observed preparing medications for a resident but failed to verify the prescription labels on the medication cards before administration. The CMA selected two medication cards from the cart without confirming they belonged to the correct resident. Upon intervention by surveyors, it was discovered that the medication cards were actually for a different resident. The CMA admitted that he would have administered the medications to the wrong resident if not stopped and was unable to describe the rights of medication administration when questioned. He also noted that the arrangement of medication cards in the cart may have been changed by night shift staff. Review of the resident's electronic medical record showed that the medications on the cards—levothyroxine sodium and propranolol—were not prescribed for the intended resident. The resident was only prescribed levothyroxine at a different dose and was not on any beta-blockers or similar cardiovascular medications. The facility's medication administration policy required staff to verify the right resident, drug, dose, dosage form, time, and route before administration, which was not followed in this instance.