Medication Error Due to Failure to Verify Resident and Orders
Penalty
Summary
The deficiency involves the facility’s failure to implement physician orders and follow its own medication administration policy, resulting in one resident receiving another resident’s medications. The facility’s “Administering Medications” policy dated December 1, 2025, required staff to check the medication label three times to verify the right resident, medication, dosage, time, and route before administration. Clinical record review showed that a resident admitted with heart failure, hypertension, and atrial fibrillation was given clonazepam (for anxiety disorders and seizures), trazodone (an antidepressant), and simvastatin (for high cholesterol). Further review revealed that these medications were actually prescribed for a different resident and there was no documented order for these medications for the resident who received them. In an interview, the Assistant Director of Nursing confirmed that staff had administered one resident’s medications to another, in violation of 28 Pa. Code 211.12(d)(1)(5) regarding nursing services.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.