Administration of Contraindicated Medications Despite Documented Allergies
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from significant medication errors. A review of clinical records, facility policy, pharmacy records, and interviews revealed that a resident with documented allergies and intolerances to several medications, including Ondansetron and Gabapentin, was administered these medications despite their allergy status. The resident's medical history included Type 2 Diabetes, congestive heart failure, and nausea and vomiting. The facility's policy required staff to verify medication allergies and obtain vital signs as applicable before administering medications. However, the resident received Ondansetron on ten occasions and Gabapentin daily for over two weeks, even though both were listed as allergies or intolerances in the resident's records. The resident reported being aware of her allergy to Ondansetron and stated that it caused her to vomit, which she had previously communicated to her physician. There was no documentation provided by the facility to show that the physician justified the use of these medications despite the allergy listings. Additionally, the consultant pharmacist's monthly reviews did not identify or recommend discontinuation of the contraindicated medications. The Nursing Home Administrator acknowledged that the medications were administered despite the documented allergies and that no physician justification could be provided.