Medication Error Rate Exceeds 5% Due to Resident Misidentification
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 26 opportunities, resulting in a 7.69% error rate. During a medication pass, a nurse prepared to administer medications intended for one resident but attempted to give them to another resident. The nurse was unfamiliar with the residents on the assigned unit and relied on names on the door and pictures in the Medication Administration Record (MAR) for identification. Despite these resources, the nurse attempted to administer the wrong medications, and only stopped when the resident pushed the medication cup away. The nurse admitted she would have given the medications to the wrong resident if not for the resident's refusal. The resident involved had a history of polyosteoarthritis and constipation, with active orders for Polyethylene Glycol and Acetaminophen. The nurse did not verify the resident's identity by asking for their name before attempting to administer the medication. Interviews with facility staff confirmed that the nurse was not familiar with the residents on the unit and did not follow established procedures for verifying resident identity prior to medication administration.