Failure to Prevent Medication Error Due to Improper Resident Identification
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A resident with diagnoses of congestive heart failure, anxiety, and atrial fibrillation, and noted to have some memory impairment, was given another resident's evening medications by an agency RN. Clinical record review and staff interview revealed that the nurse failed to correctly identify the resident using the electronic medication administration record, as required by facility procedure. The Director of Nursing confirmed that the nurse did not follow the established protocol of verifying the resident's identity by checking the picture in the electronic record and comparing it to the resident receiving the medications.