Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when staff administered multiple medications that were not prescribed for the resident. The resident had been admitted with diagnoses including cerebral infarction, type 2 diabetes, and dementia, and a recent MDS assessment documented severe cognitive impairment and dependence on staff for ADLs. During an evening medication pass, a medication technician pulled medications intended for another resident and, after becoming distracted by another resident, administered those medications to this resident at the medication cart. As a result of this error, the resident received Clozapine 200 mg, Depakote 250 mg, Niacin 250 mg, and Haldol (dose not specified), none of which were ordered for her. The facility’s own medication administration policy required the individual administering medications to verify the resident’s identity before giving medications and to check the label three times to ensure the right resident, medication, dose, time, and method. The medication technician acknowledged that she did not correctly verify the resident’s identity before administration and only realized the error after the medications had been given. Following the administration of the wrong medications, the resident developed lethargy, was difficult to rouse, was drooling, had an elevated heart rate, and experienced three episodes of emesis the next morning. Nursing staff notified the nurse practitioner, who contacted poison control, and the resident was sent to the emergency department for evaluation. Hospital records documented that the resident was admitted for unintentional ingestion of medications not prescribed for her, underwent a CT scan that showed no acute intracranial abnormality, and that her mental status returned to baseline after approximately 24 hours.
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