Medication Error Due to Failure to Verify Medication Label Against Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, resulting in a significant medication error for one resident reviewed in a sample of three. Resident #2, who had diagnoses including Parkinson’s disease, dementia, anxiety, and a history of alcohol and polysubstance abuse, was severely cognitively impaired and dependent on staff for all care. A physician’s order directed that Resident #2 receive Tramadol oral solution 50 mg by mouth twice daily. Another physician’s order directed that Resident #3 receive Lacosamide oral solution 200 mg twice daily. On the morning medication pass, the LPN responsible for administering medications poured and administered Lacosamide, which was prescribed for Resident #3, to Resident #2 instead of the ordered Tramadol. According to facility documentation and interviews, the DON reported that both Tramadol and Lacosamide were controlled substances stored in a locked area and that the medication bottles appeared similar. The DON identified that the LPN did not read the medication label prior to pouring the medication, despite the facility’s Medication Administration policy directing staff to compare the medication label to the resident’s Medication Administration Record. A nurse’s note documented that the incorrect medication was given to Resident #2 at 8:00 AM and that this was recognized and recorded later that day. The incident was also documented on a Facility Reported Incident form, which identified that Resident #2 had been given the incorrect medication.
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