**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1) when Resident 1 was assessed to be a high risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on [DATE]. Resident 1 was assessed to have an unsteady gait, educated on the need to call for assistance, had falls on [DATE], [DATE], [DATE]and fell on [DATE]. On [DATE], Resident 1 went to the bathroom unassisted, staff became aware of her presence in the bathroom alone, did not assist her with toileting, left her alone in the bathroom and Resident 1 fell and injured her right ankle. These failures resulted in Resident 1 not being provided with the level of assistance and supervision needed to prevent a fall, suffered an ankle injury requiring emergency transport to an acute care hospital for care and services and diagnosed with a fracture to the distal fibula [the lower, outer ankle area] and medial malleolus [the lower, inner ankle area]. Resident 1 was provided with a stabilizing splint, sent back to the Skilled Nursing Facility (SNF) with pain medication, new use of a Hoyer lift (an assistive device used to lift patients to transfer between a bed, chair or similar resting place) for transferring and required surgery on [DATE] in order to provide Resident 1 with the chance to walk again. Findings: During a review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), dated [DATE], the AR indicated, Resident 1 had diagnoses which included .SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE [a mental illness which can affect thoughts, mood and behavior] .METABOLIC ENCEPHALOPATHY [a change in how the brain works due to a chemical imbalance in the blood which causes confusion, memory loss and loss of consciousness] .DIFFICULTY IN WALKING .UNSTEADINESS ON FEET .ABNORMAL POSTURE .REPEATED FALLS .VERTIGO OF CENTRAL ORIGIN [spinning sensation or dizziness caused by problems within the brain] . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 10 (0-7 severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions), 8-12 moderate cognitive impairment (lessened ability to think, remember, use judgement and make decisions), 13-15 no cognitive impairment), which indicated Resident 1 had moderate cognitive impairment. During a concurrent observation and interview on [DATE] at 10:15 a.m. with Resident 1 in the Administrator ' s (ADM) office, Resident 1 was sitting on top of a Hoyer sling in her wheelchair and had a splint (a rigid material used for supporting a broken bone) with a tan bandage wrapped around her right ankle. Resident 1 stated, she fell in her bathroom alone the other day and broke her ankle badly. Resident 1 stated, she called out in a loud voice for help because she needed assistance using the bathroom. Resident 1 stated, staff did not respond in a prompt manner, so she used her wheelchair to go to the bathroom. Resident 1 stated, she used a wheelchair to ambulate because she is usually unsteady and shakes when walking. Resident 1 stated, there was a pressure alarm to her wheelchair which sounded an alarm noise when she stood up from her wheelchair. Resident 1 stated, she did not remember if the alarm went off when she stood up from her wheelchair to use the bathroom. Resident 1 stated, she slipped, hit a rail in the bathroom with her ankle, screamed in pain and fell down. During an interview on [DATE] at 10:23 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 1 required one staff member to assist her with Activities of Daily Living (ADLs- activities such as bathing, dressing, and toileting a person performs daily). CNA 1 stated, Resident 1 experienced shakiness which required two staff members to assist Resident 1 with ADLs. CNA 1 stated, Resident 1 had fallen in the facility before and was a known fall risk resident. CNA 1 stated, there were stars next to Resident 1 ' s name tag outside Resident 1 ' s room so staff were aware Resident 1 was a fall risk. CNA 1 stated, Resident 1 had an alarm on her bed and wheelchair to alert staff when she attempted to get up. During an observation on [DATE] at 10:47 a.m. in Resident 1 ' s bathroom, an emergency call button was observed on the wall next to the toilet with the words Push For Help on the button. During an interview on [DATE] at 10:54 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was alerted by staff Resident 1 was on the floor. LVN 1 stated, Resident 1 told LVN 1 she fell when she was attempting to pull up her pants. LVN 1 stated, Resident 1 screamed her ankle hurt badly. LVN 1 stated, Resident 1 ' s ankle visually looked broken, when assessed by LVN 1. LVN 1 stated, Resident 1 ' s physician was called and a call for an ambulance was made. LVN 1 stated, it was important to provide residents with adequate supervision to prevent accidents because Resident 1 ' s safety was the staff ' s priority, and she should have had access to the help she needed. During an interview on [DATE] at 11:12 a.m. with CNA 2, CNA 2 stated, on [DATE], she heard Resident 1 was found on the floor so she went to Resident 1 ' s bathroom to help. CNA 2 stated, she heard Resident 1 say, Ouch! Ouch! and saw Resident 1 ' s ankle was damaged. CNA 2 stated, prior to the fall, the AM[CE1] (daytime shift) Program Manager (AMPM) had responded to Resident 1 ' s wheelchair alarm ringing. CNA 2 stated, Resident 1 declined help from the AMPM so the AMPM left Resident 1 in the bathroom. CNA 2 stated, the AMPM returned to Resident 1 and found Resident 1 on the floor. CNA 2 stated, the AMPM should have pushed the emergency call light in the bathroom and stayed with Resident 1 until another staff member arrived to help. CNA 2 stated, Resident 1 had fallen in the past. CNA 2 stated, she reminded Resident 1 to use the call light because staff did not want Resident 1 to fall and get hurt causing unnecessary pain. During an interview on [DATE] at 11:40 a.m. with the AMPM, the AMPM stated, on [DATE], she had checked on Resident 1 because she heard Resident 1 ' s wheelchair alarm going off. The AMPM stated, Resident 1 was using the bathroom and declined help from the AMPM. The AMPM stated, she left Resident 1 on the toilet, turned off the wheelchair alarm, and went back to her office. The AMPM stated, she did not notify any other staff member Resident 1 was still on the toilet. The AMPM stated, she heard Resident 1 yell out shortly after, went to check on Resident 1 and found her on the floor. During a concurrent interview and record review on [DATE] at 11:53 a.m. with the Director of Nursing (DON), Resident 1 ' s Care Plan Report (CPR), dated [DATE], and Resident 1 ' s MORSE FALL SCALE [CE2] (MFS- An assessment tool that predicts the likelihood that a resident will fall), dated [DATE] were reviewed. The CPR indicated, .[Resident 1] is a high fall risk [as evidenced by] .Repeated falls .Unsteadiness on feet .Abnormal posture .Difficulty in walking .Psychoactive [affecting the mind] drug use .Vertigo of central origin .age related osteoporosis [weak and brittle bones due to lack of calcium and Vitamin D] .right ankle fracture [DATE] due to fall XXX[DATE] Witnessed fall with [Head Injury Protocol (HIP)- facility protocol in which staff assesses and monitors the resident after a suspected or identified head injury] .Fall with HIP [DATE] .Unwitnessed Fall [DATE] without HIP, [DATE] with no HIP .Interventions XXX[DATE]: intervention will be to educate staff and resident about assisting resident fully when resident is using the restroom and ensure their safety when transferring .Anticipate and meet [Resident 1] ' s needs .Follow facility fall protocol .Interventions is to communicate with [Resident 1], encourage her to ask for assistance when attempting to ambulate, utilize the call lights, and make sure her wheelchair is locked before attempting to sit in or get out of it . The MFS indicated, .Score: 50 .High Risk for Falling .Has the Resident ever fallen before? .Yes . The DON stated, on [DATE], Resident 1 ' s wheelchair alarm was going off so the AMPM went to help Resident 1. The DON stated, Resident 1 declined help from the AMPM, the AMPM left and did not notify patient care staff Resident 1 was in the bathroom. The DON stated, Resident 1 fell after the AMPM had left Resident 1 in the bathroom. The DON stated, Resident 1 was not being actively supervised every time she went to the bathroom. The DON stated, Resident 1 ' s CPR included the intervention to educate staff and Resident 1 about assisting Resident 1 fully when Resident 1 used the restroom and ensured her safety when transferring. The DON stated, Resident 1 ' s MFS indicated she was a high risk for falls with a score of 50. The DON stated, Resident 1 was in the Falling Star Program (a program where staff could identify and intervene for residents who have had a fall within the last 30 days). The DON stated, Resident 1 had stars next to her name tag by her room doorway which alerted staff she was in the Falling Star Program. The DON stated the AMPM knew Resident 1 was a high risk for falls. The DON stated, it was important to provide Resident 1 with adequate supervision to prevent accidents to avoid any risk of falls and injuries. During a concurrent phone interview and record review on [DATE] at 1:37 p.m. with the Assistant Director of Nursing (ADON), Resident 1 ' s MDS Section GG- Functional Status (MDSGG), dated [DATE] was reviewed. The MDSGG indicated, .Self-Care .Coding: .Supervision or touching assistance- Helper provides verbal cues and/or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently .[Resident 1] .Toileting hygiene: The ability to maintain perineal [area between the genitals and anus] hygiene, adjust clothes before and after voiding or having a bowel movement Signed .on [March] 4, 2025 .Supervision or touching assistance . The ADON stated, according to the MDS Section GG, Resident 1 required supervision or touching assistance with toileting. The ADON stated, this meant Resident 1 required assistance with cleaning or help with anything else while toileting. The ADON stated, a staff member responded to Resident 1 ' s wheelchair alarm ringing and found Resident 1 using the bathroom. The ADON stated the staff member left Resident 1 alone in the bathroom then Resident 1 had an unwitnessed fall. The ADON stated, Resident 1 was sent to the emergency room because her ankle was misaligned and was screaming. The ADON stated, Resident 1 was diagnosed with a right ankle fracture at the emergency department [ED]. The ADON stated the staff member who responded to Resident 1 should have pushed the emergency call button in the bathroom to alert more staff to come to assist the resident instead of leaving Resident 1 unassisted in the bathroom. The ADON stated Resident 1 ' s care plan indicated to educate staff and Resident 1 about calling for staff assistance and to ensure safety when transferring. The ADON stated, Resident 1 needed constant reminders for safety and had a history of falls. The ADON stated, Resident 1 had prior falls on [DATE], [DATE] and [DATE]. The ADON stated, Resident 1 was on the Falling Star program which meant there were stars on the name tag by Resident 1 ' s room door so all staff recognized Resident 1 had a fall within the last 30 days. The ADON stated, it was important to provide Resident 1 with adequate supervision to prevent falls. During a phone interview on [DATE] at 10:45 a.m. with the DON, the DON stated, Resident 1 ' s fall was avoidable. During a phone interview on [DATE] at 2:37 p.m. with the DON, the DON stated, Resident 1 returned from the hospital ED with an oxycodone/acetaminophen (pain medication) prescription to alleviate her pain. The DON stated, Resident 1 had an open reduction internal fixation (ORIF) surgery (surgical procedure used to repair broken bones) of the right ankle on [DATE]. During a review of Resident 1 ' s Progress Notes (PN), dated [DATE], the PN indicated, .At [1:25 p.m.], Staff alerted me that [Resident 1] was on the floor in her bathroom. Upon arrival to resident ' s bathroom, I was informed that this was an unwitnessed fall and that [Resident 1] did not hit her head. [Resident 1] reported having pain in her right foot, and upon assessment, [Resident 1] ankle appeared to be displaced. I asked another nurse to assist with contacting [ambulance company name] to send [Resident 1] to the hospital [Resident 1] claimed that her pain was 9/10 [a numerical pain scale assessment tool used to quantify the intensity of pain by having an individual rate their pain on a numbered scale, with 1-3 typically representing mild pain, 4-6 moderate pain, and 7-10 severe pain] . [Resident 1] stated that she was trying to pull up her pants and transfer herself back to her wheelchair, but the wheels were not locked, and she fell. Initially, [Resident 1] stated that only her Right Foot/leg area were in pain, but when [ambulance company name] showed up at [1:45 p.m.], She told them that her back was also hurt during the fall. [Ambulance company name] splinted her Right Ankle/Foot with a pillow .Author: [LVN] . During a review of Resident 1 ' s Post Fall Assessment (PFA), dated [DATE], the PFA indicated, .Date and Time of Fall: [DATE] [1:25 p.m.] .Where was the resident when they fell? Residents ' bathroom .What was the resident doing when they fell? Transferring from toilet to wheelchair .[wheelchair] brakes were unlocked . [Resident 1] stated that she was trying to pull up her pants and transfer herself back to her wheelchair but the wheels were not locked and she fell .Was this fall observed? No .possible ankle fracture .Sent to acute facility .Date of most recent prior fall XXX[DATE] . During a review of Resident 1 ' s PN, dated [DATE], the PN indicated, .[7:00 p.m.] [Resident 1] returned from acute [diagnosis] right ankle [fracture] .Right ankle in splint. [Resident] able to move toes on right foot with .complaints of discomfort .Reports pain level 8/10 [severe pain according to the numerical pain scale assessment tool] to right ankle . During a review of Resident 1 ' s Hospital Patient Education & Visit Summary (PEVS), dated [DATE], the PEVS indicated, .[Resident 1] .[brought in by ambulance] from [Skilled Nursing Facility (SNF) facility] reporting unwitnessed [ground level fall] .right ankle deformity observed upon arrival .Patient Diagnosis .Ankle fracture, right .PATIENT EDUCATION INSTRUCTIONS .After an ankle fracture, you can lose ankle mobility and muscle strength and endurance . During a review of Resident 1 ' s Hospital Orthopedic [pertaining to the bones and muscles] Consultation Note (OCN), dated [DATE], the OCN indicated, REASON FOR CONSULTATION: Right ankle fracture .presents to the emergency department via ambulance from [facility] status post [after] unwitnessed ground-level fall .on the ground after an unwitnessed fall, complained of right ankle pain and was noted to have a deformity of the right ankle .ED workup revealed right ankle fracture and orthopedic surgery was consulted .ground level fall with closed right bimalleolar ankle fracture [type of fracture where both the inner and outer ankle are fractured] .leave splint in place until [follow up (f/u)] .closed reduction [a procedure to realign a fractured bone by manipulating it back into its correct position without surgery] and splinting performed in the ED .Patient is stable for discharge home from an orthopedic standpoint with outpatient follow up .in 7-10 days .[X-RAY (XR)- a form of medical imaging to take pictures of the inside of the body] Ankle Complete .Right .IMPRESSION .Acute [sudden onset] displaced [to move from the original position] fractures [breaks] of the distal fibula and medial malleolus .Orthopedic surgery consultation recommended . During a review of Resident 1 ' s PN, dated [DATE], the PN indicated, .I accompanied [Resident 1] to her .[orthopedic] appointment today .After reviewing the notes from her [emergency room (ER)] visit on [DATE] and the x-ray images taken that day, [Orthopedic Surgery Doctor of Medicine (OSMD)] asked [Resident 1] if she ' [wanted] to be able to walk again ' , to which [Resident 1] replied that she want the option to try walking again. [OSMD] then explained that she would need surgery if she wanted the opportunity to walk and that is she did not care to walk again, then nothing needed to be done other than to let her ankle heal naturally. [Resident 1] then stated her desire for surgery and agreed with [OSMD] ' s Plan of Care. [OSMD] then stated that [Resident 1] ' s surgery would be ' next Thursday ' . During a review of Resident 1 ' s PN, dated [DATE], the PN indicated, .Resident returned from surgery .with Orthopedics. Resident had an Open- Reduction- Internal- Fixation of Right Ankle and a Popliteal Nerve block [a technique used to numb the leg, foot, and ankle for procedures like surgery] . During a review of Resident 1 ' s Hospital Encounter Summary (ES), dated [DATE], the ES indicated, .Diagnoses .RIGHT ANKLE BIMALLEOLAR FRACTURE XXX[DATE] .Surgery .RIGHT ANKLE OPEN REDUCTION INTERNAL FIXATION .Medications at Time of Discharge .HYDROcodone/acetaminophen [pain medication] .10 [milligrams- unit of measurement (mg)]/325mg [tablet (tab)] .Take one Tab by mouth every 6 hours as needed .Indications: Closed displaced bimalleolar fracture of right ankle .HISTORY OF PRESENT ILLNESS: [Resident 1] .presents today with right ankle fracture .She reports sustaining the injury in the bathroom. Reduction was done .on [DATE]. She reports pain and rates the pain at 10/10 [severe pain according to the numerical pain scale assessment tool] .After discussion, she is interested in proceeding with surgical intervention . During a review of the facility ' s policy and procedure (P&P) titled, FALL PREVENTION & MANAGEMENT, dated [DATE], the P&P indicated, .It is the goal of this facility to prevent or reduce the occurrence of falls and severity of fall-related injuries while improving the quality of life for our residents and clients .Upon admission, each resident is assessed using a Fall Risk Assessment tool to determine possible risk for sustaining a fall .Residents scoring high per the risk assessment process, have strategies implemented to reduce the potential for falls outlined in their plan of care .Resident who have actively sustained a fall, will be placed on the facility ' s heightened awareness program (i.e., Falling Star), designed to alert staff of a resident who has actively fell in the presence of standard fall prevention interventions .Visual identifiers will be used to identify residents on the program. Those identifiers may be placed on the nameplate outside the resident ' s room . During a professional reference review retrieved from https://rn-journal.com/journal-of-nursing/preventing-falls-in-the-elderly-long-term-care-facilities, titled Preventing Falls in the Elderly Long Term Care Facilities, undated, .The elderly long-term care population is at increased risk for falls and fall related injuries. The implementation of a fall prevention program is important for ensuring resident safety. Systematically assessing residents ' risk for falls and implementing appropriate fall prevention interventions can reduce the number of falls in the elderly long-term care residents .Falls can cause serious injuries and accidental death, in older people .The elderly in long-term care facilities are predisposed to falling and may fall for a variety of reasons. Predisposing factors include, unsteady gait [a person ' s manner of walking] and balance, weak muscles .Staff should be educated about predisposing [to give a tendency to beforehand] and precipitating [to bring something on] factors for falls and related prevention strategies and interventions . Staff needs to understand the different interventions available to them, in order to apply them when caring for patients .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 administered psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications not prescribed to Resident 1 in error. This failure resulted in Resident 1's transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for decreased mental status and treatment of an accidental overdose (dangerous and excessive dose of a drug). (Cross reference F 726, F 760) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking) was slow and steady. Resident 1 stated a male nurse had given her another resident's medications and she was sent to the hospital but did not remember the exact day. Resident 1 stated the nurse handed her a medication cup. Resident 1 stated she looked at the medication and told the nurse they were not hers. Resident 1 stated, he [LVN 1] was saying nonchalantly [casually] they were my meds. Resident 1 stated she knew the medicine was not hers because they were different shapes and sizes than what she usually took. Resident 1 stated she swallowed the pills and the nurse suddenly realized he had given her the wrong medication. Resident 1 stated she became sleepy and was transferred to the hospital but did not remember anything for the rest of the day. During a review of Resident 1's admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included anemia (blood produces lower than normal amount of healthy red blood cells), rheumatoid arthritis (inflammatory disorder affecting the joints), schizoaffective disorder-bipolar type (mental illness that can affect your thoughts, mood and behavior) and tachycardia (rapid heart rate). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Nurses Note, dated 3/6/24 at 11:54 a.m., by Unit Manager (UM) 1, the nurses note indicated, . During 0800 [8:00 a.m.] med [medication] pass Charge nurse made me aware that [Resident 1] had received peers [Resident 4's] medications in error . [Resident 1] received Carbamazepine [used to treat bipolar disorder] 200 mg [milligram-unit of measurement], [brand name for Divalproex Sodium (used to treat bipolar disorder)] 125 mg, [brand name for haloperidol (antipsychotic medication)] 0.5 mg, [brand name for quetiapine (antipsychotic medication)] 400 mg, Vitamin D [nutritional supplement] 1000 un [units (unit of measurement)], Multi vit [multiple vitamin] and oxybutynin [used to treat an overactive bladder] . During a review of Resident 4's Order Summary Report, (OSR) dated 3/2024, the OSR indicated, . CarBAMazepine Oral [by mouth] Tablet . Give 200 mg by mouth one time a day for anger/mood . [brand name] Oral Tablet Delayed Release (Divalproex Sodium) give 125 mg by mouth one time a day . Haloperidol Oral Tablet . Give 0.5 mg by mouth one time a day . multiple vitamin tablet give 1 tablet by mouth one time a day . oxyBUTYnin Chloride Oral Tablet . Give 5 mg by mouth two times a day . QUEtiapine Fumarate Oral Tablet . Give 400 mg one time a day . vitamin D3 oral tablet . Give 1000 IU [international unit-unit of measurement for vitamins and other medical products] by mouth one time a day . During an interview on 3/11/24 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had worked at the facility for approximately one year and was familiar with Resident 1. CNA 1 stated Resident 1's baseline was alert, oriented and ambulatory (walking) without assistance. During an interview on 3/11/24 at 12:23 p.m. with CNA 2, CNA 2 stated last Wednesday (3/6/24) LVN 1 had asked for her help identifying residents during the medication pass. CNA 2 stated LVN 1 was new and not familiar with the residents. CNA 2 stated LVN 1 had asked her who Resident 1 was and she replied with Resident 1's first and last name. CNA 2 stated she had repeated Resident 1's first and last name to LVN 1 at least four times while he administered the medication to make sure he had the correct resident. CNA 2 stated LVN 1 administered the medications to Resident 1 and then pulled out an inhaler. CNA 2 stated she notified LVN 1 Resident 1 did not use an inhaler. CNA 2 stated LVN 1 asked her, this isn't [Resident 4's name]? CNA 2 stated LVN 1 walked away and spoke with Unit Manager (UM) 1. CNA 2 stated she was later notified Resident 1 had received Resident 4's medication and Resident 1's vital sign had to be checked every 30 minutes. CNA 2 stated when she took Resident 1 a snack around 10:00 a.m. and Resident 1 was drowsy. CNA 2 stated Resident 1 was sent to the hospital around 11:05 a.m. because she was groggy, and her respirations (action of breathing) were slower than normal. During an interview on 3/11/24 at 12:50 p.m. with Resident 4, Resident 4 stated the staff confused her with Resident 1 sometimes because their last names were similar. During a concurrent interview and record review on 3/11/24 at 1:37 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 1 had worked at the facility since 10/2023. The DSD stated she met with LVN 1 after the medication error on 3/6/24. The DSD stated LVN 1 reported he had given Resident 1's medication to Resident 4. The DSD stated Resident 1 was transferred to the emergency department (ED) as a result of the medication error. The DSD stated LVN 1's medication pass competency had been performed by one of the DSD Assistants in February 2024. LVN 1's competency titled, Medication Pass Observation Worksheet, dated 2/21/24 was reviewed, the observation indicated, . Medication Administration . Hands washed/sanitized using appropriate technique [No] . Label checked times three (including expiration, description) [No] . MAR [Medication Administration Record] initialed immediately after administration [No] . Number of errors [0] . The DSD stated the facility required 100% on the medication pass observation competency. The DSD stated since LVN 1 did not check the medication label correctly or initial the MAR timely the form should not indicate there were zero errors. The DSD stated she or a DSD Assistant should have followed up on LVN 1's medication pass competency. The DSD stated a repeat observation was not done and there was no documentation of training performed at the time of the observation. The DSD stated the expectation was for the nurses to follow the rights of medication administration, verifying the right person, right medication, right time, right dose and right documentation. During a telephone interview on 3/11/24 at 2:45 p.m. with LVN 1, LVN 1 stated he worked the Station 3 I hallway on 3/6/24. LVN 1 stated he was not familiar with the residents, so he took a CNA to help identify the residents. LVN 1 stated there were two residents with similar last names. LVN 1 stated he asked the CNA who a resident was, and she stated the resident was Resident 1. LVN 1 stated he heard Resident 4's last name in error and gave Resident 4's medication to Resident 1. LVN 1 stated when he took Resident 4's inhaler out of the med cart and handed it to Resident 1, Resident 1 said she did not use an inhaler. LVN 1 stated he asked the CNA if there was another resident with a similar name and the CNA told him Resident 4. LVN 1 stated he realized he gave Resident 4's medication to Resident 1 in error. LVN 1 stated, she [Resident 1] went from being fine to not fine. Her [Resident 1's] respirations dropped from 17 to 13 per minute. LVN 1 stated, she became very sedated [calm or to make drowsy by administering a sedating drug] because she got the wrong meds. LVN 1 stated Resident 1's mental status had changed, and the physician ordered for her to be transferred to the ED. LVN 1 stated he believed the medication error was caused because he was not familiar with the residents and the residents' similar names. During a concurrent interview and record review on 3/11/24 at 4:55 p.m. with the Director of Nursing (DON), LVN 1's Medication Pass Observation Worksheet, dated 2/21/24 was reviewed. The Medication Pass Observation Worksheet, indicated LVN 1 failed to check the label three times and initial the MAR immediately after administration. The DON stated it was her understanding the DSD assistant had addressed the medication pass observation issues at the time of the observation but was unable to provide documentation it had occurred. The DON stated it was her expectation the number of errors would not be zero on the observation and there should have been a repeat medication pass observation done. During a telephone interview on 3/12/24 at 9:49 a.m. with LVN Unit Manager (UM) 1, UM 1 stated on 3/6/24 at approximately 8:00 a.m. LVN 1 notified her he had made a medication error. UM 1 stated LVN 1 reported he administered Resident 4's medication to Resident 1. UM 1 stated she had assessed Resident 1 shortly after the medication error and notified the physician. UM 1 stated the physician saw Resident 1 later in the morning and sent her to the ED because she was sedated. UM 1 stated Resident 1 was a little bit tired and had her eyes closed but was able to answer questions. The UM stated the medication error was caused by LVN 1 failing to do his three checks of resident identification during the medication pass. During a telephone interview on 3/12/24 at 11:23 a.m. with the Pharmacy Consultant (PC), the PC stated she had been the facility's consultant since 2022. The PC stated she was at the facility on 3/6/24 for the quarterly medication pass observations. The PC stated LVN 1 was passing medication when she arrived, so she observed him. The PC stated LVN 1 did not properly identify the residents during the medication pass and continued to rely on the CNAs. The PC stated LVN 1 was new and could have avoided the medication error by asking Resident 1 her name and date of birth instead of relying on a coworker. During a telephone interview on 3/13/24 at 10:40 a.m. with UM 2, UM 2 stated he was doing rounds with Resident 1's physician on the morning of 3/6/24. UM 2 stated Resident 1's physician assessed Resident 1 and she was speaking slowly and not alert. UM 2 stated the physician was later contacted and notified Resident 1's respiratory rate had dropped to 13 per minute and the physician ordered Resident 1's transfer to the ED. During a review of Resident 1's Physician's Progress Note, dated 3/6/24 at 11:58 a.m., written by the physician (PHY), the note indicated, . 77 yo [year old] . presents for monthly visit . seen secondary to pt [patient] getting NOTHER [another] Patients meds . carbamazepine 200 [mg] . [brand name for divalproex sodium] 125 [mg] . [brand name for haloperidol] 0.5 [mg] . oxybutynin 5 [mg] . [brand name for quetiapine] 400 [mg] . vit [vitamin] D 1000 IU [international units] pt barely arousable-follow commands RR [respiratory rate] low 13 [breaths per minute] sent to hospital . During a review of the GACH's document titled, ED Provider Notes, dated 3/6/24, the ED notes indicated, . Patient presents with . Altered mental status [decreased level of consciousness] . Physical Exam . Gen [general]: Very somnolent [state of feeling drowsy, ready to fall asleep] . Neuro [neurological-pertaining to the nervous system (brain, nerves and spinal cord)]: Initial exam: Somnolent, but arousable to voice. Unable to speak full sentences . [Resident 1's name] is a [AGE] year old female . who presents with somnolence, near obtundation (diminished responsiveness to stimuli [anything that can trigger a physical or behavioral change], often due to a state of reduced consciousness) after receiving multiple sedating [drugs that calm] and psychotropic medications [drugs that affect a person's mental state] due to medication error at her SNF [skilled nursing facility] . Poison control [specialized unit that advises on and assists in the prevention and management of poisoning] consulted, the recommend monitoring until somnolence resolved . ED Diagnosis . Accidental overdose . During a review of the GACH's document titled, Hospitalist [physician who cares for hospitalized patients] Discharge Summary, dated 3/8/24, the discharge summary indicated, . admit date [DATE] . discharge date [DATE] . Reason for admission . Altered mental status (BIBA [brought in by ambulance] from [name of facility] for being lethargic after receiving the wrong medications (carbamazepine 200 mg, [brand name for divalproex sodium] 125 mg, [brand name for haloperidol] 0.5 mg, [brand name for quetiapine] 400 mg) none of which are her routine medications.) . presented with AMS [altered mental status], lethargy [lack of energy], and difficulty ambulating [walking] after being given the wrong medications in error . only [brand name for divalproex sodium] is her normal medication . Poison control recommended cardiac monitoring [records heart rate and rhythm], supportive care and to washout the meds from body systems . In ED, pt became more arousable but still having difficulty ambulating . Patient was admitted for Accidental CNS [central nervous system-brain and spinal cord which controls all of the body's functions] meds overdose , on 3/07/24 . Discharge Diagnoses . Accidental overdose . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/carbamazepine-oral-route/side-effects/drg-20062739 titled, Carbamazepine (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . confusion, agitation, or hostility (especially in elderly) . loss of balance control . tiredness . unusual drowsiness . During a review of a professional reference retrieved fromhttps://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/side-effects/drg-20072886 titled, Divalproex Sodium (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . problems with memory or speech . shakiness in the legs, arms, hands, or feet . sleepiness or unusual drowsiness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/side-effects/drg-20064173 titled, Haloperidol (Oral Route), dated 3/1/2024, the reference indicated . Side Effects . loss of balance . weakness of the arms and legs . dizziness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=1 titled, Quetiapine, dated 3/1/2024, the reference indicated, . Side Effects . confusion . sleepiness or unusual drowsiness . During a review of the facility's policy and procedure (P&P) titled Med Pass, Medication Administration Essentials, dated 9/1/13 and revised on 9/18/23, the P&P indicated, . Medications are administered by a licensed nurse in a safe and dignified manner . Medications and treatments are to be administered as prescribed . The licensed nurse shall check the resident's identity by armband, photo or other means of identification prior to administering medication . Medication Errors . The nurse shall notify the physician immediately after a medication error has been noted . The nurse will assess and monitor the resident closely for any adverse effects from medication error . The nurse shall document in resident's record what medication was administered and observations .The Director of Nursing Service/designee shall complete follow-up for medication errors and take necessary corrective action . During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/#:~:text=It%20is%20crucial%20that%20nurses,do%20so%20in%20clinical%20practice. titled, Nursing Rights of Medication Administration, dated 9/4/2023, the reference indicated, . Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights' . of medications administration . ' Right Patient' . ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed . this is best practiced by nurses directly asking a patient to provide his or her full name aloud . It is advisable not to address patients by first name or surname [last name] alone, in the event, there are two or more patients with identical or similar names in a unit . nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of significant medication errors when Licensed Vocational Nurse (LVN) 1 did not correctly identify Resident 1 and administered Resident 4's psychoactive (medication that changes brain function and results in alterations in perception, mood, consciousness, cognition [pertaining to reasoning, memory and judgement], or behavior) medications to her in error. This failure resulted in Resident 1 experiencing a change in mental status which required a transfer to the emergency department (ED) and admission to the general acute care hospital (GACH) for an accidental overdose (dangerous and excessive dose of a drug) of medication. (Cross reference F 658, F 726) Findings: During a concurrent observation and interview on 3/11/24 at 11:39 a.m. with Resident 1 in the dining room, Resident 1 finished her meal, stood without assistance and walked down the hallway. Resident 1's gait (a person's manner of walking) was slow and steady. Resident 1 stated a male nurse had given her another resident's medications and she was sent to the hospital but did not remember the exact day. Resident 1 stated the nurse handed her a medication cup. Resident 1 stated she looked at the medication and told the nurse they were not hers. Resident 1 stated, he was saying nonchalantly [casually] they were my meds. Resident 1 stated she knew the medicine was not hers because they were different shapes and sizes than what she usually took. Resident 1 stated she swallowed the pills and the nurse suddenly realized he had given her the wrong medication. Resident 1 stated she became sleepy and was transferred to the hospital but did not remember anything for the rest of the day. During a review of Resident 1's admission Record (AR-a document with person identifiable and medical information), undated, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included anemia (blood produces lower than normal amount of healthy red blood cells), rheumatoid arthritis (inflammatory disorder affecting the joints), schizoaffective disorder-bipolar type (mental illness that can affect your thoughts, mood and behavior) and tachycardia (rapid heart rate). During a review of Residents 1's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 1's Brief Interview of Mental status assessment (BIMS – assessment of cognitive status for memory and judgement) scored 14 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Nurses Note, dated 3/6/24 at 11:54 a.m., by Unit Manager (UM) 1, the nurses note indicated, . During 0800 [8:00 a.m.] med [medication] pass Charge nurse made me aware that [Resident 1] had received peers [Resident 4's] medications in error . [Resident 1] received Carbamazepine [used to treat bipolar disorder] 200 mg [milligram-unit of measurement], [brand name for Divalproex Sodium (used to treat bipolar disorder)] 125 mg, [brand name for haloperidol (antipsychotic medication)] 0.5 mg, [brand name for quetiapine (antipsychotic medication)] 400 mg, Vitamin D [nutritional supplement] 1000 un [units (unit of measurement)], Multi vit [multiple vitamin] and oxybutynin [used to treat an overactive bladder] . During a review of Resident 4's Order Summary Report, (OSR) dated 3/2024, the OSR indicated, . CarBAMazepine Oral [by mouth] Tablet . Give 200 mg by mouth one time a day for anger/mood . [brand name] Oral Tablet Delayed Release (Divalproex Sodium) give 125 mg by mouth one time a day . Haloperidol Oral Tablet . Give 0.5 mg by mouth one time a day . multiple vitamin tablet give 1 tablet by mouth one time a day . oxyBUTYnin Chloride Oral Tablet . Give 5 mg by mouth two times a day . QUEtiapine Fumarate Oral Tablet . Give 400 mg one time a day . vitamin D3 oral tablet . Give 1000 IU [international unit-unit of measurement for vitamins and other medical products] by mouth one time a day . During an interview on 3/11/24 at 12:13 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had worked at the facility for approximately one year and was familiar with Resident 1. CNA 1 stated Resident 1's baseline was alert, oriented and ambulatory without assistance. During an interview on 3/11/24 at 12:23 p.m. with CNA 2, CNA 2 stated last Wednesday (3/6/24) LVN 1 had asked for her help identifying residents during the medication pass. CNA 2 stated LVN 1 was new and not familiar with the residents. CNA 2 stated LVN 1 had asked her who Resident 1 was and she replied with Resident 1's first and last name. CNA 2 stated she had repeated Resident 1's first and last name to LVN 1 at least four times while he administered the medication to make sure he had the correct resident. CNA 2 stated LVN 1 administered the medications to Resident 1 and then pulled out an inhaler. CNA 2 stated she notified LVN 1 Resident 1 did not use an inhaler. CNA 2 stated LVN 1 asked her, this isn't [Resident 4's name]? CNA 2 stated LVN 1 walked away and spoke with Unit Manager (UM) 1. CNA 2 stated she was later notified Resident 1 had received Resident 4's medication and Resident 1's vital sign had to be checked every 30 minutes. CNA 2 stated when she took Resident 1 a snack around 10:00 a.m. and Resident 1 was drowsy. CNA 2 stated Resident 1 was sent to the hospital around 11:05 a.m. because she was groggy, and her respirations (action of breathing) were slower than normal. During an interview on 3/11/24 at 12:50 p.m. with Resident 4, Resident 4 stated the staff confused her with Resident 1 sometimes because their last names were similar. During a concurrent interview and record review on 3/11/24 at 1:37 p.m. with the Director of Staff Development (DSD), the DSD stated LVN 1 had worked at the facility since 10/2023. The DSD stated she met with LVN 1 after the medication error on 3/6/24. The DSD stated LVN 1 reported he had given Resident 1's medication to Resident 4. The DSD stated Resident 1 was transferred to the emergency department (ED) as a result of the medication error. The DSD stated LVN 1's medication pass competency had been performed by one of the DSD Assistants in February 2024. LVN 1's competency titled, Medication Pass Observation Worksheet, dated 2/21/24 was reviewed, the observation indicated, . Medication Administration . Hands washed/sanitized using appropriate technique [No] . Label checked times three (including expiration, description) [No] . MAR [Medication Administration Record] initialed immediately after administration [No] . Number of errors [0] . The DSD stated the facility required 100% on the medication pass observation competency. The DSD stated since LVN 1 did not check the medication label correctly or initial the MAR timely the form should not indicate there were zero errors. The DSD stated she or a DSD Assistant should have followed up on LVN 1's medication pass competency. The DSD stated a repeat observation was not done and there was no documentation of training performed at the time of the observation. The DSD stated the expectation was for the nurses to follow the rights of medication administration, verifying the right person, right medication, right time, right dose and right documentation. During a telephone interview on 3/11/24 at 2:45 p.m. with LVN 1, LVN 1 stated he worked the Station 3 I hallway on 3/6/24. LVN 1 stated he was not familiar with the residents, so he took a CNA to help identify the residents. LVN 1 stated there were two residents with similar last names. LVN 1 stated he asked the CNA who a resident was, and she stated the resident was Resident 1. LVN 1 stated he heard Resident 4's last name in error and gave Resident 4's medication to Resident 1. LVN 1 stated when he took Resident 4's inhaler out of the med cart and handed it to Resident 1, Resident 1 said she did not use an inhaler. LVN 1 stated he asked the CNA if there was another resident with a similar name and the CNA told him Resident 4. LVN 1 stated he realized he gave Resident 4's medication to Resident 1 in error. LVN 1 stated, she [Resident 1] went from being fine to not fine. Her [Resident 1's] respirations dropped from 17 to 13 per minute. LVN 1 stated, she became very sedated [calm or to make drowsy by administering a sedating drug] because she got the wrong meds. LVN 1 stated Resident 1's mental status had changed, and the physician ordered for her to be transferred to the ED. LVN 1 stated he believed the medication error was caused because he was not familiar with the residents and the residents' similar names. During a concurrent interview on 3/11/24 at 4:55 p.m. with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and Administrator (ADM), the ADON stated, I think it [the medication error] was caused by the inexperience of a new nurse not knowing the patients. The ADON stated the medication error caused Resident 1 to have a change in condition including a lowered heart rate and being a little shaky. The ADON stated Resident 1 was transferred to the hospital and they flushed her system due to the amount of medications she had received. The ADON stated the medication error caused Resident 1's change in condition and she was admitted to the hospital from [DATE] until 3/8/24. The DON stated Resident 1 was not prescribed Quetiapine and was closely monitored because of potential side effects from the medication. During a concurrent interview and record review on 3/11/24 at 4:55 p.m. with the DON, LVN 1's Medication Pass Observation Worksheet, dated 2/21/24 was reviewed. The Medication Pass Observation Worksheet, indicated LVN 1 failed to check the label three times and initial the MAR immediately after administration. The DON stated it was her understanding the DSD assistant had addressed the medication pass observation issues at the time of the observation but was unable to provide documentation it had occurred. The DON stated it was her expectation the number of errors would not be zero on the observation and there should have been a repeat medication pass observation done. During a telephone interview on 3/12/24 at 9:49 a.m. with LVN Unit Manager (UM) 1, UM 1 stated on 3/6/24 at approximately 8:00 a.m. LVN 1 notified her he had made a medication error. UM 1 stated LVN 1 reported he administered Resident 4's medication to Resident 1. UM 1 stated she had assessed Resident 1 shortly after the medication error and notified the physician. UM 1 stated the physician saw Resident 1 later in the morning and sent her to the ED because she was sedated. UM 1 stated Resident 1 was a little bit tired and had her eyes closed but was able to answer questions. The UM stated the medication error was caused by LVN 1 failing to do his three checks of resident identification during the medication pass. During a telephone interview on 3/12/24 at 11:23 a.m. with the Pharmacy Consultant (PC), the PC stated she had been the facility's consultant since 2022. The PC stated she was at the facility on 3/6/24 for the quarterly medication pass observations. The PC stated LVN 1 was passing medication when she arrived, so she observed him. The PC stated during LVN 1 did not properly identify the residents during the medication pass and continued to rely on the CNAs. The PC stated LVN 1 was new and could have avoided the medication error by asking Resident 1 her name and date of birth instead of relying on a coworker. During a telephone interview on 3/13/24 at 10:40 a.m. with UM 2, UM 2 stated he was doing rounds with Resident 1's physician on the morning of 3/6/24. UM 2 stated Resident 1's physician assessed Resident 1 and she was speaking slowly and not alert. UM 2 stated the physician was later contacted and notified Resident 1's respiratory rate had dropped to 13 per minute and the physician ordered Resident 1's transfer to the ED. During a review of Resident 1's Physician's Progress Note, dated 3/6/24 at 11:58 a.m., written by the physician (PHY), the note indicated, . 77 yo [year old] . presents for monthly visit . seen secondary to pt getting NOTHER [another] Patients meds . carbamazepine 200 [mg] . [brand name for divalproex sodium] 125 [mg] . [brand name for haloperidol] 0.5 [mg] . oxybutynin 5 [mg] . [brand name for quetiapine] 400 [mg] . vit [vitamin] D 1000 IU [international units] pt [patient] barely arousable-follow commands RR [respiratory rate] low 13 [breaths per minute] sent to hospital . During a review of the GACH's document titled, ED Provider Notes, dated 3/6/24, the ED notes indicated, . Patient presents with . Altered mental status [decreased level of consciousness] . Physical Exam . Gen [general]: Very somnolent [state of feeling drowsy, ready to fall asleep] . Neuro [neurological- pertaining to the nervous system (brain, nerves and spinal cord)]: Initial exam: Somnolent, but arousable to voice. Unable to speak full sentences . [Resident 1's name] is a [AGE] year old female . who presents with somnolence, near obtundation (diminished responsiveness to stimuli [anything that can trigger a physical or behavioral change], often due to a state of reduced consciousness) after receiving multiple sedating [drugs that calm] and psychotropic medications [drugs that affect a person's mental state] due to medication error at her SNF [skilled nursing facility] . Poison control [specialized unit that advises on and assists in the prevention and management of poisoning] consulted, the recommend monitoring until somnolence resolved . ED Diagnosis . Accidental overdose . During a review of the GACH's document titled, Hospitalist [physician who cares for hospitalized patients] Discharge Summary, dated 3/8/24, the discharge summary indicated, . admit date [DATE] . discharge date [DATE] . Reason for admission . Altered mental status (BIBA [brought in by ambulance] from [name of facility] for being lethargic after receiving the wrong medications (carbamazepine 200 mg, [brand name for divalproex sodium] 125 mg, [brand name for haloperidol] 0.5 mg, [brand name for quetiapine] 400 mg) none of which are her routine medications.) . presented with AMS [altered mental status], lethargy [lack of energy], and difficulty ambulating [walking] after being given the wrong medications in error . only [brand name for divalproex sodium] is her normal medication . Poison control recommended cardiac monitoring [records heart rate and rhythm], supportive care and to washout the meds from body systems . In ED, pt became more arousable but still having difficulty ambulating . Patient was admitted for Accidental CNS [central nervous system-brain and spinal cord which controls all of the body's functions] meds overdose , on 3/07/24 . Discharge Diagnoses . Accidental overdose . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/carbamazepine-oral-route/side-effects/drg-20062739 titled, Carbamazepine (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . confusion, agitation, or hostility (especially in elderly) . loss of balance control . tiredness . unusual drowsiness . During a review of a professional reference retrieved fromhttps://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/side-effects/drg-20072886 titled, Divalproex Sodium (Oral Route), dated 3/1/2024, the reference indicated, . Side Effects . problems with memory or speech . shakiness in the legs, arms, hands, or feet . sleepiness or unusual drowsiness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/side-effects/drg-20064173 titled, Haloperidol (Oral Route), dated 3/1/2024, the reference indicated . Side Effects . loss of balance . weakness of the arms and legs . dizziness . During a review of a professional reference retrieved from https://www.mayoclinic.org/drugs-supplements/quetiapine-oral-route/side-effects/drg-20066912?p=1 titled, Quetiapine, dated 3/1/2024, the reference indicated, . Side Effects . confusion . sleepiness or unusual drowsiness . During a review of the facility's policy and procedure (P&P) titled Med Pass, Medication Administration Essentials, dated 9/1/13 and revised on 9/18/23, the P&P indicated, . Medications are administered by a licensed nurse in a safe and dignified manner . Medications and treatments are to be administered as prescribed . The licensed nurse shall check the resident's identity by armband, photo or other means of identification prior to administering medication . Medication Errors . The nurse shall notify the physician immediately after a medication error has been noted . The nurse will assess and monitor the resident closely for any adverse effects from medication error . The nurse shall document in resident's record what medication was administered and observations .The Director of Nursing Service/designee shall complete follow-up for medication errors and take necessary corrective action . During a review of a professional reference retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/#:~:text=It%20is%20crucial%20that%20nurses,do%20so%20in%20clinical%20practice. titled, Nursing Rights of Medication Administration, dated 9/4/2023, the reference indicated, . Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration . It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the ' five rights' . of medications administration . ' Right Patient' . ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed . this is best practiced by nurses directly asking a patient to provide his or her full name aloud . It is advisable not to address patients by first name or surname [last name] alone, in the event, there are two or more patients with identical or similar names in a unit . nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence .