F0760

D

Wrong-Resident Medication Administration Due to Failure to Follow Five Rights

Columbus, Indiana Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to follow the facility’s medication administration guidelines, specifically the five rights of medication administration, resulting in a resident receiving another resident’s medications. A family member reported that while visiting Resident D, a staff member attempted to perform a blood sugar test related to insulin use, even though Resident D was not diabetic and had never been on insulin; the family member stopped the staff member from performing the test. Later, the same family member was notified that Resident D had received the wrong medications. Resident D’s clinical record showed moderate cognitive impairment with diagnoses including osteoporosis and dementia, and the EMAR indicated that at the 9:00 P.M. medication pass the resident was to receive atorvastatin, donepezil, and Zetia.

During an interview, QMA 2 stated that on the night in question she was using the 200 Hall medication cart for the first time and was distracted by another resident talking to her while at the cart. She had two cups of pills prepared, one with two medications and one with three medications, for residents in nearby rooms, Resident D and Resident E. After administering medications to Resident D, she realized at the cart that she had given Resident D Resident E’s 9:00 P.M. medications instead of Resident D’s ordered medications. Resident E’s EMAR showed that the 9:00 P.M. medications included Keppra 500 mg and metformin 1000 mg, each ordered twice daily between 6:00 A.M.–10:00 A.M. and 6:00 P.M.–10:00 P.M. The facility’s written policy required verification of the right resident, right drug, right dose, right route, and right time with a triple check at three steps in the preparation process, which was not followed in this incident.