Significant Medication Error Due to Failure in Resident Identification
Penalty
Summary
A deficiency occurred when a nurse administered seven medications to a resident that were actually prescribed for another individual. The facility's medication administration policy required nurses to verify the resident's identity, check the drug label multiple times, and ensure the five rights of medication administration, including right resident, right drug, right dose, right route, and right time. Despite these protocols, the nurse failed to verify the correct resident and did not administer the medications at the ordered time, resulting in the resident receiving medications not intended for them. The resident involved had diagnoses of dementia, hyperlipidemia, and anxiety, with severe cognitive impairment documented. However, the resident was generally able to state their name when asked, and staff confirmed that the resident could usually identify themselves. The error was discovered after the nurse realized the mistake and reported it. Interviews with staff confirmed that the nurse did not follow the required procedures for resident identification and medication administration. The facility's investigation found that the nurse did not practice safe medication administration and failed to perform the five rights. The incident was considered a significant medication error, and the nurse responsible was terminated. The event was documented through interviews, record reviews, and direct observation of the resident, who appeared alert and engaged following the incident.