Failure to Address Documented Medication Allergy
Penalty
Summary
A resident with a diagnosis including congestive heart failure was admitted to the facility with a documented allergy to acetaminophen (Tylenol), as noted in her hospital discharge records. Despite this, the facility's physician orders included acetaminophen for general discomfort, and the medication was administered to the resident on multiple occasions over a two-month period. The allergy was not added to the resident's care plan until several months after her admission, even though both the resident and her daughter had informed staff of the allergy, and the hospital discharge documentation clearly indicated it. Interviews with the Director of Nursing (DON) revealed that staff failed to recognize and address the documented acetaminophen allergy upon the resident's return from the hospital. The DON acknowledged that the allergy should have been documented and addressed earlier, especially after the resident reported her inability to take acetaminophen during a care plan meeting. The facility's Medication Administration policy required verification of allergies before administering medications, but this protocol was not followed in this case.