Failure to Administer Ordered Pre-Procedural Medication for Allergy Prevention
Penalty
Summary
A resident with a history of heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease, and known allergies to iodine and contrast dye, was scheduled for an angiogram. Pre-procedure instructions required the resident to receive three doses of prednisone to prevent an allergic reaction due to the known allergy. The instructions were communicated to nursing staff, and the orders were to be transcribed onto the Medication Administration Record (MAR). However, the order for the three doses of prednisone was not transcribed onto the MAR, and there was no documentation that the resident received any of the required doses prior to the procedure. The omission was discovered when the resident’s wife inquired about the medication, and staff confirmed that no order for prednisone was present in the system. As a result, the resident did not receive the prescribed pre-procedure medication as required by the facility’s policy for safe and timely medication administration.