Resident Provided Incorrect Medications at Discharge
Penalty
Summary
A deficiency occurred when a nurse at discharge provided a resident with blister packs containing medications that belonged to two other residents, rather than the resident's own prescribed medications. The resident, who had a history of diabetes mellitus and hypertension and was determined to have the mental capacity to make medical decisions, ingested pantoprazole (Protonix) before realizing the error. The medication was not prescribed to her, and the error was confirmed by the Director of Nursing as a mistake that should not have happened. Following ingestion of the incorrect medication, the resident experienced adverse symptoms including body aches, vomiting, hives, and elevated blood pressure, which required hospital evaluation and monitoring. The facility's policy required the discharge nurse to ensure medication reconciliation at discharge, but this process was not followed, resulting in the resident receiving and ingesting another resident's medication.