Failure to Manage Resident's Opioid Allergies
Penalty
Summary
The facility failed to ensure the safe and effective use of medications for a resident, identified as R148, who had documented allergies to several opioids. The resident was admitted with multiple diagnoses, including spinal stenosis and chronic pain syndrome, and had a known allergy to opioids such as fentanyl, hydrocodone, hydromorphone, morphine, oxycodone, and codeine. Despite these documented allergies, a physician's order included oxycodone, which the resident was allergic to, and tramadol, which the resident suspected might cause a milder allergic reaction. Interviews with the resident and facility staff confirmed the presence of documented opioid allergies in the resident's clinical records. The physician, identified as Employee E5, acknowledged the oversight and stated that oxycodone had been discontinued, leaving the resident on tramadol. Additionally, the facility administrator, identified as Employee E1, admitted that the facility lacked a policy addressing allergies, which contributed to the oversight in medication management for the resident.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 medications were reviewed with physician to identify any allergies and adjusted as needed. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all medication allergies are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that medication allergy orders are followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.