Significant Medication Error Due to Failure to Verify Resident Identity and Report Incident
Penalty
Summary
A significant medication error occurred when a nurse administered another resident's medications to a resident with severe cognitive impairment. The resident, who had a history of traumatic subdural hemorrhage, dysphagia, pleural effusion, metabolic encephalopathy, anemia, and was severely cognitively impaired, received medications including Rivaroxaban, Nifedipine, Flomax, and Insulin Lispro that were not prescribed for him. The nurse did not verify the resident's identity prior to administration, as required by facility policy, and did not report the error to the supervisor or the primary care physician. Following the administration of the incorrect medications, the resident developed nausea and vomiting and was subsequently hospitalized for an upper gastrointestinal bleed. The medication error was not documented in the resident's medical record or medication administration record. The facility only became aware of the incident after being notified by the hospital several days later, as the nurse involved did not report the error or document it in any facility records. Interviews with facility staff revealed that neither the CNA nor the unit manager were aware of the medication error at the time it occurred. The nurse responsible for the error was not available for interview, and the facility's investigation began only after external notification. The lack of immediate reporting and documentation of the medication error, as well as failure to follow established medication administration protocols, contributed to the deficiency.