Failure to Notify Hospital of Medication Error During Resident Transfer
Penalty
Summary
A resident with multiple complex medical conditions, including chronic pain, diabetes, stage 5 chronic kidney disease, heart failure, dependence on renal dialysis, and pulmonary edema, received another resident's morning medications in error. The incident was immediately reported to the nursing supervisor, Director of Health Services (DHS), and Nurse Practitioner (NP), who assessed the resident and implemented orders to monitor for potential side effects. The resident was made aware of the error, and an attempt was made to notify his wife. The resident was subsequently transferred to a local hospital. Upon transfer, the facility failed to notify the receiving hospital that the resident had received the wrong medications prior to admission. There was no documentation provided to the hospital regarding the medication error, and the hospital only became aware of the incident after the resident's family member obtained and delivered the information. Interviews with facility staff confirmed that it was expected for the nurse transferring the resident to report such incidents, but there was no policy in place outlining what should be communicated to the hospital during transfers.