Failure to Prevent Administration of Allergen-Containing Medication
Penalty
Summary
A deficiency occurred when a resident with multiple documented allergies, including to sulfamethoxazole, was administered Bactrim DS, an antibiotic containing this allergen. The resident was admitted with a history of spinal stenosis, diabetes mellitus, hypertension, peripheral vascular disease, and other conditions. Upon admission, the resident's allergies were recorded in the facility's records, but a breakdown in communication and documentation led to the allergy not being properly updated in the pharmacy system. As a result, the pharmacy did not flag the order for Bactrim DS as contraindicated. The process failure began when an LPN received a telephone order for Bactrim DS after the resident exhibited symptoms of a urinary tract infection. The LPN bypassed a safety alert in the electronic medical record, incorrectly assuming that the provider was aware of the resident's allergy. The order was not properly verified with the provider, and the allergy was not communicated during the order entry process. The medication was administered from the emergency kit, and subsequent doses were given without further alerts, as the system did not continue to flag the allergy after the initial override. The resident experienced an allergic reaction, including flushing, redness, and rash, after receiving multiple doses of Bactrim DS. Staff interviews revealed confusion about the process for handling allergy alerts, the responsibilities for verifying allergies, and the communication between nursing staff, providers, and the pharmacy. The pharmacy's records were incomplete due to the allergy not being updated, and the facility's policies for medication orders and allergy documentation were not consistently followed, directly leading to the resident's exposure to a known allergen and resulting harm.