Failure to Evaluate and Address Medication Allergies
Penalty
Summary
The facility failed to properly evaluate and address medication allergies for two residents. For one resident with a history of respiratory failure, COPD, pneumonia, and chronic inflammatory demyelinating polyneuritis, records showed an allergy to Bactrim with a previously observed mild adverse reaction resulting in increased serum creatinine. Despite this documented allergy, the resident was prescribed and administered Bactrim DS on multiple occasions, and the provider overrode the allergy alert without documented consultation or follow-up in the electronic health record. The Director of Nursing confirmed that the allergy was not addressed at the time of order entry and that there was no facility policy regarding medication allergies. Another resident with acute respiratory failure and documented allergies to aspirin, codeine, penicillin, and zaleplon was prescribed Diclofenac sodium gel, a nonsteroidal anti-inflammatory drug. An alert for a possible drug allergy was generated in the electronic medical record, but there was no evidence of evaluation or follow-up regarding the potential allergy to Diclofenac. The Director of Nursing confirmed that no follow-up was completed and that the facility lacked a policy for addressing potential drug allergies when alerts were triggered.