F0760

K

Significant Medication Error and Systemic Failures in Resident Identification

Tunkhannock, Pennsylvania Survey Completed on 04-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to implement effective procedures to accurately identify residents prior to medication administration. Facility policy required that medications be administered by licensed nurses in accordance with professional standards and that residents be identified by photograph in the electronic health record before medication administration. The admission policy also required that a resident photograph be obtained and uploaded to the electronic health record to ensure accurate identification. Despite these policies, the facility did not consistently maintain resident photographs in the electronic health record and did not have a reliable alternative identification process, particularly for cognitively impaired residents and for staff unfamiliar with the residents.

One critical event involved two cognitively impaired residents who shared a room. One resident, admitted with senile degeneration of the brain and a BIMS score of 5 indicating severe cognitive impairment, had physician orders for morphine sulfate concentrate 20 mg/ml, 0.5 ml by mouth once daily, and levothyroxine sodium 25 mcg daily in the morning. The roommate, admitted with dementia and a BIMS score of 3 indicating severe cognitive impairment, did not have these medication orders. An agency RN, on her second shift in the facility and unfamiliar with the residents, entered the shared room to administer medications, called out the name of the resident for whom the morphine and levothyroxine were ordered, and the roommate responded "huh." Without verifying identity using a photograph or another reliable method, the nurse administered the morphine sulfate 0.5 ml and levothyroxine 25 mcg intended for the first resident to the roommate.

After administering the medications, the agency RN realized at the computer that the medications had been given to the wrong resident. She immediately obtained the roommate’s vital signs, which showed blood pressure 90/50 mm Hg, heart rate 38 beats per minute, respirations 12, and oxygen saturation 98%, and contacted 911, the physician, and the resident representative. Emergency department documentation later confirmed that the resident arrived with accidental opiate poisoning and profound bradycardia, with reported heart rates as low as 29 beats per minute and low blood pressures, and required two doses of naloxone to stabilize heart rate and blood pressure before being discharged back to the facility the same day.

Beyond this event, the facility’s systemic failure to maintain an effective resident identification system contributed to the deficiency. Observations showed that during medication administration, some residents did not have photographs in the electronic health record, even though the system had a designated location for such photos. Staff interviews confirmed that nurses relied primarily on electronic photographs to identify residents, but several residents lacked these photographs. Staff also reported using familiarity with residents, asking residents to state their names when cognitively intact, or relying on room nameplates, and they were unable to describe a consistent method for identifying cognitively impaired residents. Clinical record review identified multiple residents without photographs uploaded until surveyor inquiry, and staffing records showed that agency nurses comprised a portion of licensed staff, increasing the likelihood that unfamiliar staff would depend on incomplete identification tools. The DON confirmed the medication error, the reliance on photographs for identification, and that the admissions position previously responsible for uploading photographs had been eliminated, with no documented competency validation or specific training on resident identification procedures for the agency RN involved.

Plan Of Correction

Facility completed resident identification pictures in the electronic medical records for residents 48, 53, 65, 6, 7, 12, 59, 34, 23 on 4/9/2026. All resident photos uploaded and audited on same date.
2. Audit of all residents completed on 4/9/2026 to ensure photos of all residents were present in their medical chart for identification purposes.
3. Facility procedures for Medication Administration, Resident Admission Procedure and Orientation checklist for LPN/RN were reviewed and updated to reflect the taking of photographs of new residents upon admission and place in the electronic medical record for resident identification, completed on 4/9/2026. Residents received wrist bands on 4/13/2026 with exception of 5 residents who refused to have a wrist band as a secondary method of identification. Agency RN marked as a "do not return" to facility and agency was updated to mediation error on 4/7/2026. Education completed with facility licensed nurses on 4/9/2026 and ongoing on policies and procedures, resident identification, secondary identifications with use of wrist band, and 5 rights of medication administration.
4. New admission audits will be completed by the NHA/designee to ensure photo identification is uploaded to the EMR. QA committee notified of the IJ and abatement plan of correction. New admission audits for picture identification will continue daily X 2 months with results of audits to QA committee for review and alternative actions as required. DON/designee will audit nurses administering medications to ensure the 5 rights of medication pass are followed and all residents have accurate resident identification prior to medications administration is identified in 3 resident med passes, 3 X week for 4 weeks.
5. April 25, 2026

Removal Plan

• Identify residents who do not have photographs in the electronic health record.
• Take resident photographs and upload them to the electronic health record; photograph any residents not available immediately upon their return and upload promptly.
• Audit all residents’ electronic health records to verify photographs are present for identification purposes and review the system process for resident identification.
• Order wristbands for all residents containing the resident’s name and date of birth as a secondary identification method.
• Update resident photographs in the electronic health record as necessary and review them annually during resident care planning meetings by the Social Services Director or designee.
• Ensure resident photographs are taken on the day of admission and uploaded to the electronic health record, and apply a medical wristband with resident name and date of birth per the admission procedure.
• Provide education for LPNs and RNs on the five rights of medication administration and use of electronic health record photographs for resident identification, and make education on obtaining and uploading photographs available.
• Provide the agency staffing company a copy of the education materials to be completed by agency staff prior to accepting shifts and update the agency orientation packet to include the revised admission procedure and updated medication administration policy.
• Audit new admissions to ensure photographs are uploaded appropriately into the electronic health record.
• Conduct daily audits of photograph identification for new admissions for two months, and report results to the Quality Assurance Committee for review and alternative actions as required.