Failure to Identify and Address Resident Allergy During Medication Review
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's allergy to metformin was properly identified and addressed during the monthly medication regimen review by the consulting pharmacist. The resident, who had multiple diagnoses including type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, had a documented allergy to metformin in the allergy alert profile. However, this allergy was not consistently reflected in the resident's care plan, and a physician order for metformin was entered and administered despite the known allergy. The medication administration record showed that metformin was given daily for 24 days by four different nurses, even though the allergy was documented in the resident's profile and flagged in the electronic physician order system. There was no documentation that the resident's representative or the physician was notified about the new order for metformin or the resident's allergy to the medication. Additionally, the pharmacy's monthly review did not document the irregularity of the metformin order in the presence of the allergy, and the consulting pharmacist assumed the allergy had been previously addressed without further investigation. Interviews with facility staff and pharmacy representatives revealed a lack of communication and follow-up regarding the allergy and the medication order. The Director of Nursing confirmed that nurses should check for allergies before administering medications and that the resident's representative should have been notified. The consulting pharmacist acknowledged that the allergy should have been investigated further during the monthly review. Facility policies required pharmacists to review medication regimens and report irregularities, as well as evaluate new medication orders for allergies, but these procedures were not followed in this case.