Administration of Medication Despite Documented Allergy
Penalty
Summary
A resident with a documented allergy to tubersol was administered a Mantoux test using tubersol, despite clear indications in the admission paperwork and on the Medication Administration Record (MAR) that the resident had an allergy to this substance. The allergy was noted in the resident's records, although the specific reaction was not detailed. The nurse administered the test and only realized the allergy after the fact, at which point the Nurse Practitioner (NP) was notified. The resident was monitored and experienced a mild skin reaction at the injection site, which was managed according to subsequent medical orders. Interviews with facility staff, including the Director of Nursing (DON), pharmacist, NP, and Administrator, confirmed that the allergy was documented and should have been checked prior to administration. The pharmacist emphasized the risk of administering a medication to someone with a known allergy, and the NP stated that staff are expected to verify orders before giving any medication. The incident was attributed in part to previous instability in the DON position, which had led to ongoing medication errors within the facility.