Failure to Verify Resident Identity Resulting in Wrong Medication Administration
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when a registered nurse administered another resident’s medications without properly verifying identity. The resident, who had diagnoses including hypertension, hypothyroidism, hyperlipidemia, anemia, history of falls, and a history of right femur fracture, required staff assistance with medication administration and had intact cognition. During a morning medication pass, the nurse entered the resident’s room, stated, “I have your medicine,” and proceeded to administer multiple medications—Amlodipine, Bupropion, Lisinopril, Paxil, and Prednisone—that were not prescribed for this resident. The nurse later documented that she had not verified she had the correct resident before administering the medications. The error was discovered when the nurse attempted to administer a Lovenox injection, and the resident questioned this, stating she had never received a shot at the facility. At that point, the nurse left the room, checked the medications, and realized she had been in the wrong room and had given the wrong medications. The resident later confirmed in an interview that she had been given medications by a nurse she had never seen before and that she questioned the nurse when a shot was attempted. The resident’s family also reported that the resident had called them at the time to report she had been given the wrong medications. The current DON confirmed that the nurse had administered the wrong medications, and review of the facility’s medication administration policy showed that staff were required to verify resident identity before giving medications, which did not occur in this incident.
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