Medication Administration Errors Due to Resident Misidentification
Penalty
Summary
The facility failed to administer medications as ordered for two residents, resulting in each receiving another resident's medications. In the first incident, a resident with diagnoses including acute kidney failure, Type 2 diabetes, and schizophrenia, and who was cognitively intact, was given another resident's insulin doses. The error occurred when an agency LPN, while administering morning insulins, relied on a CNA's identification of the resident, which was based on a visual cue (a red blanket) rather than proper identification protocols. The resident responded affirmatively to the wrong name when called, and the LPN administered both long-acting and short-acting insulin intended for another resident. The error was discovered when the LPN noticed a different name tag on the resident's door. The resident was subsequently sent to the emergency room for observation due to the risk of hypoglycemia, though she was asymptomatic at the time of transfer. In the second incident, another resident with a history of hypertension, septicemia, aphasia, and stroke, and with moderately impaired cognition, was administered a full set of morning medications intended for a different resident. The error was made by an Oral Medication Technician (OMT) who was unfamiliar with both residents, as they were new to the facility and had similar names. The OMT administered the medications after the resident answered affirmatively to the wrong name. The error was realized when the OMT saw the correct name outside the door after leaving the room. The resident received medications including antihypertensives and diuretics, and subsequent blood pressure monitoring showed several low diastolic readings, though no immediate side effects were observed by staff. Both incidents involved failures to properly identify residents before medication administration, despite facility policy requiring the use of two identifiers and positive identification before giving medications. In both cases, staff relied on verbal confirmation or visual cues rather than following established procedures for resident identification. These failures resulted in residents receiving medications not intended for them, necessitating additional monitoring and medical intervention.