Medication Errors Due to Failure to Verify Resident Identity and Inaccurate Room Identification
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate administration of medications for two residents when a medication technician administered each resident the other’s medications. On the morning of 9/11/25, MT-G gave one resident a set of medications that included furosemide 40 mg, potassium ER 10 mEq, donepezil 25 mg, metoprolol ER 50 mg, sertraline 50 mg, memantine 5 mg, and ursodiol 300 mg instead of the resident’s prescribed allopurinol 100 mg, amlodipine 2.5 mg, multivitamin, cyanocobalamin 1000 mcg, and isosorbide mononitrate ER 30 mg. This resident had been admitted earlier that month with diagnoses including malignant neoplasm of the bladder, infection and inflammatory reaction due to an indwelling urethral catheter, and was receiving palliative care, with a BIMS score of 6 indicating severely impaired cognition. The resident’s medication occurrence report documented that the wrong medications were administered and that the resident did not have a picture in the facility’s medical record system, and the medical record lacked a progress note regarding the medication error. The second resident, admitted with diagnoses including acute osteomyelitis of the left ankle and foot, aneurysm of the ascending aorta, cerebral infarction, and transient ischemic attack, with a BIMS score of 11 indicating moderately impaired cognition, was administered the first resident’s medications on the same morning. The medication occurrence report for this resident also documented that the wrong medications were given and that the resident did not have a picture in the medical record system, and the medical record similarly lacked a progress note regarding the medication error. The Nursing Home Administrator confirmed that the two residents received each other’s morning medications, that MT-G did not complete the six rights of medication administration, and that the name plaques outside both residents’ doors were incorrect due to a room change and failure to update the plaques. The Administrator also confirmed there was no education provided regarding the accuracy of residents’ name plaques or the importance of entering residents’ pictures into the medical record system upon admission.
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