Failure to Prevent Administration of Allergic Medication
Penalty
Summary
A facility failed to prevent a significant medication error involving a 78-year-old female resident with multiple documented allergies, including Hydrocodone. Despite clear documentation of the resident's Hydrocodone allergy on her face sheet, care plan, nurse report sheet, hospital discharge paperwork, and medication record, she was administered 10 doses of Hydrocodone-Acetaminophen over several days. The Hydrocodone was initially ordered by a hospital physician, but the facility's staff administered the medication without identifying or acting on the documented allergy. Multiple licensed vocational nurses (LVNs) administered the Hydrocodone doses, and the pharmacy consultant reviewed the resident's case without making any recommendations. Interviews with family members confirmed that the allergy was reported to staff upon admission, although the specific staff member was not recalled. The resident herself was unaware she had received Hydrocodone and did not recall being forced to take it, but reported mental disturbances associated with its administration, as relayed by her family. There were no documented notes of negative outcomes such as rashes or hives in the nurse's or progress notes during the period of administration. Interviews with facility staff, including the ADON, administrator, nurse practitioner, and pharmacist, confirmed that the resident's allergy to Hydrocodone was documented and that she should not have received the medication. The facility's policy required checking allergies before administering new medications, and in-service training on this topic had been conducted. Despite these protocols, the allergy was not identified or acted upon, resulting in the administration of a medication to which the resident was allergic.