Significant IV Medication Error Due to Failure to Follow Five Rights
Penalty
Summary
A resident with multiple traumatic fractures (including left calcaneus with delayed healing, left first metatarsal, left tibia and fibula shafts, left acetabulum, left pubis, and left ileum) related to a motorcycle injury, and additional diagnoses of anemia, intestinal obstruction, and hypertension, had an active order for IV Vancomycin HCl in dextrose solution (1 g/200 ml, 1.75 mg three times daily) for a bacterial wound infection from 10/11/25 through 10/20/25. The resident’s MDS dated 12/28/25 documented intact cognitive function. On one night in October, around midnight, the resident reported that an RN administered an IV medication, and after the infusion was completed, the resident noticed the medication label showed another resident’s name and immediately informed the nurse. Subsequent interviews with two RNs, including a unit manager, confirmed that the nurse administered Zosyn (Piperacillin/Tazobactam 3.375 g/100 ml) instead of the ordered Vancomycin on that date. Progress notes documented that this medication error occurred, specifying that Piperacillin/Tazobactam was given in place of Vancomycin. The DON stated that nurses are expected to follow the facility’s medication administration policy, which requires verification of the “five rights” (right patient, right drug, right dose, right route, right time) and use of two resident identifiers before administering medications. The documented error shows that these required checks were not effectively carried out, resulting in the resident receiving the wrong IV medication.
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