Medication Error Due to Misidentification of Resident During Orientation
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality by administering a full set of medications intended for one resident to another. Resident #1, who had moderately impaired cognition with a BIMS score of 10 and was non-ambulatory and used a wheelchair, received multiple medications not prescribed for him, including aspirin, buspirone, calcium, carvedilol, vitamin D, glipizide, isosorbide, jardiance, lisinopril, metformin, and tamsulosin. A progress note by the ARNP documented that Resident #1 received medications he did not normally take in error. The error occurred when Staff A, an LPN on her second shift and still in orientation, was told by Staff B, an LPN, that Resident #6 was in the dining room and that she could give his medications. Staff A prepared the medications and, after asking for clarification on which resident was Resident #6, administered them to Resident #1, mistakenly believing he was Resident #6. Staff A called Resident #1 by Resident #6’s name and he responded, and she proceeded with administration until Staff B returned and noticed Staff A about to give eye drops to Resident #1, who did not receive eye drops. Staff B then verified that Resident #1 had received medications intended for Resident #6. The facility’s medication administration policy required staff to verify resident identity by checking the photograph in the medical record and, if necessary, confirming with other personnel, but this verification process was not followed.
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