Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A resident received another resident’s medications, resulting in a significant medication error. On the morning of 1/29/26 at approximately 8:30 AM, an agency LPN administered a set of medications that were prescribed for a different resident. The medications given included Norvasc 5 mg, ferrous sulfate 325 mg, a fiber tablet, Lasix 10 mg, a multivitamin, potassium chloride 10 mEq, vitamin D3 25 mcg, Florastor, liquid protein, and risperidone 2 mg, none of which were prescribed for the resident who received them. The resident later reported that she tried to tell the nurse the pills were not hers, but the nurse insisted they were and did not ask her name or otherwise confirm her identity before administration. The resident stated she developed a severe headache and felt unwell afterward and noted she had never been prescribed risperidone before. The facility’s medication error report identified that the agency LPN gave the wrong medications and documented contributing factors as inexperienced staff and an old photo of the resident. The ADON confirmed that the resident received the wrong medications and that the LPN recognized the error immediately after administration. At the time of the incident, the resident remained alert and oriented x4, with no immediate symptoms documented other than later sleepiness. The facility’s medication administration policy required licensed nurses to follow the six rights of medication administration, including verifying the right resident, but this verification process was not followed when the LPN failed to properly identify the resident before giving the medications.
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