F0760

J

Significant Medication Error from Incorrect Medication Reconciliation

Berkeley Heights, New Jersey Survey Completed on 02-04-2026

Penalty

Fine: $22,925

Summary

The deficiency involves a failure to ensure that a resident was free from significant medication errors during the admission and medication reconciliation process. A resident identified as having diagnoses including influenza, depression, cerebral infarction, hyperlipidemia, hypertension, and cardiac arrhythmia was admitted to the facility. An LPN/Unit Manager (LPN/UM) was responsible for reviewing the admission packet and reconciling the resident’s medications. While transcribing the medication list, which was on multiple pages, the LPN/UM did not verify that each page belonged to the correct resident and mistakenly used another resident’s medication list. As a result, medications prescribed for a different resident were entered into this resident’s electronic medical record and medication administration record (MAR).

Review of the January MAR and order summary report for the admitted resident showed that several medications not ordered for this resident by the transferring facility were listed and administered. These included furosemide 20 mg daily, lithium carbonate ER 450 mg daily, trazodone 100 mg at bedtime, clonazepam 0.5 mg twice daily, and risperidone 3 mg twice daily. The transferring facility’s medication list for this resident did not contain any of these medications. Further review of records showed that these medications actually belonged to another resident with diagnoses including schizoaffective disorder, heart failure, and hypertension. The LPN/UM’s written statement confirmed that she failed to verify that each page of the multi-page medication list was for the correct resident, which led to entering the wrong medications and providing inaccurate information to the provider when obtaining verbal orders.

The MAR documented that the wrong medications were administered over multiple days. Clonazepam and risperidone were given starting on the day of admission and continued on subsequent days; trazodone was administered at bedtime on several consecutive nights; and furosemide and lithium were administered daily on multiple mornings. The error was discovered only after the resident’s representative informed facility staff that the medications on the list were not accurate and reported that the resident was not completing sentences. The facility’s investigation, interviews with staff, and review of the medical record confirmed that the medication reconciliation process was not performed correctly, that the LPN/UM used another resident’s medication list, and that the attending physician had been provided with incorrect medication information when admission orders were obtained.

Removal Plan

• Assess and monitor the resident for any adverse reaction, including vital signs and level of consciousness; initiate and maintain neurological checks until the resident is sent out for further evaluation.
• Initiate an investigation into the incident and suspend the identified LPN/UM pending the outcome of the investigation.
• Audit all new admissions and re-admissions (including discharged medication reconciliation records) to ensure accuracy, proper transcription, physician orders, and compliance with the facility's admission protocol.
• Provide re-education for licensed nursing staff on the facility's admission process, medication reconciliation requirements, nurse accountability, and resident identification procedures.
• Educate licensed nursing staff on a protocol requiring two-nurse verification for transcription and review of hospital discharge medication lists and use of two resident identifiers prior to medication transcription and administration.