Failure to Protect Resident from Medication Allergy
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the administration of a medication to which the resident was allergic. The resident, who had been diagnosed with unspecified dementia, hypertension, and renal insufficiency, was admitted to the facility with documented allergies to hydralazine, naproxen, and penicillin. Despite this, a registered nurse administered hydralazine to the resident after receiving a verbal order from a physician to manage the resident's high blood pressure. The nurse had access to the resident's clinical record, which included the allergy information, but failed to notice it. Following the administration of hydralazine, the resident experienced a hypertensive episode and was found to have dark coffee ground emesis, indicating potential gastrointestinal bleeding. The pharmacy later notified the nursing staff of the resident's allergy to hydralazine, prompting a reevaluation of the resident's condition. The resident's family was informed of the situation and requested that the resident be transferred to a hospital for further evaluation and treatment. The facility's failure to recognize and act upon the documented allergy resulted in the resident being exposed to a medication that could cause harm.
Plan Of Correction
This plan of correction constitutes my written allegation of compliance for the deficiencies in which the facility was cited for. However, the submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by state and federal law. - Immediately during complain survey, ERS submitted for Neglect on 12/18/2024. - All medication errors will be screened for abuse/neglect and reported if it meets criteria to ERS. - Electronic Medical Record feature activated for alert for all residents, related to resident allergies to specific medications, to populate red/pink screen alerting RN/LPN to allergy. - Licensed nursing staff will receive education on N-M-05 Medication Administration General Guidelines and N-M-300 Medication Documentation and N-M-150 Medication Error Reporting, Analysis and Correction (MERF). - DON/ADON/Designee to audit all medication errors for abuse/neglect weekly x4 and bi-weekly x2. - Results of audit will be reviewed and evaluated at QAPI meeting.