F0760

D

Wrong-Resident Medication Administration Due to Failure to Verify Identity

Saginaw, Michigan Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent significant medication errors when an LPN administered a set of medications intended for one resident to another resident with the same first name. The facility’s own "Medication Administration General Guidelines" policy required that residents be identified using a minimum of two identifiers before medication administration and that medications supplied for a specific resident not be administered to others. During the incident, the nurse did not verify the resident’s identity with two identifiers, and the resident who received the wrong medications did not have an ID bracelet on his arm at the time. The nurse entered the wrong room and provided a handful of 4–5 pills, a chocolate nutritional supplement, and a nasal spray to the resident, who reported that he does not receive a nasal spray and does not like chocolate supplements.

The resident who received the wrong medications (Resident #101) had been admitted with diagnoses including prosthetic left hip joint fracture, nondisplaced subtrochanteric fracture of the left femur, abnormal gait and mobility, chronic kidney disease, benign prostatic hyperplasia, and asthma. His MDS showed he was cognitively intact with a BIMs score of 15/15, and his advance directives indicated full code status. After receiving the medications, he reported feeling lightheaded and "high," describing feeling as if he had smoked multiple marijuana cigarettes, and stated he did not recall everything that happened because he was "out of it." He later informed staff that he believed he had received extra medications that morning. Vital sign documentation for him on the day of the incident showed a blood pressure of 113/70, pulse 95, and respirations 19 in the early morning, with no further vital signs recorded until the evening.

The medications administered in error to Resident #101 were identified through pharmacy review as Eliquis 5 mg (anticoagulant), Entresto 24-26 mg (antihypertensive cleared through kidneys), Jardiance 10 mg (for diabetes/heart failure, cleared through kidneys), Lopressor 50 mg (beta blocker antihypertensive), and Spironolactone 25 mg (diuretic antihypertensive cleared through kidneys). These medications belonged to another resident (Resident #102), who had multiple serious medical diagnoses including MRSA, sepsis, bacteremia, pneumonia, long-term IV Vancomycin therapy, embolism and thrombosis, cardiomyopathy, left bundle branch block, tachycardia, heart failure, hypertension, hyponatremia, dysphagia, autistic disorder, epilepsy, anemia, and anxiety disorder, and whose advance directives indicated DNR status. The LPN involved acknowledged in interview that she made a mistake by giving the wrong medications to the wrong resident with the same first name and stated that the other resident did not receive his medications. The pharmacist, when asked if this constituted a significant medication error, stated it was a subjective, simple mistake and noted that resident rights of medication administration are a nursing issue at the point of administration. The facility’s occurrence reporting policy required reporting and investigation of medication-related incidents and harmful unintended results caused by taking medications, but the report documents that the ADON became aware of the possible medication error only later that evening after staff notification.