Failure to Prevent Administration of Medication Despite Documented Allergy
Penalty
Summary
A deficiency occurred when a resident with multiple documented medication allergies, including an allergy to metformin, was prescribed and administered metformin without proper clarification from the physician. The resident had a history of type two diabetes mellitus, schizoaffective disorder, bipolar disorder, atrial fibrillation, hypertension, and dysphagia, and was noted to have impaired cognition. The allergy to metformin was recorded in the resident's allergy alert profile, but was not included in the care plan, and subsequent physician orders for metformin were entered despite the allergy being flagged in the electronic medical record. The medication administration record showed that metformin was administered daily for 24 days by four different nurses, with no documentation that the resident's representative or the physician was notified about the allergy or the new medication order. The pharmacy's documentation acknowledged the allergy, but there was no evidence that the pharmacy communicated this to the facility or that the consultant pharmacist addressed the issue during monthly reviews. The facility's policies required evaluation of medication allergies with new orders, but this process was not followed in this case. Interviews with the DON and pharmacy staff revealed a lack of awareness and communication regarding the allergy and the medication order. The DON confirmed that nurses should check for allergies before administering medications and that the resident's representative should have been notified. The consulting pharmacist admitted to assuming the allergy had been previously addressed and did not investigate further. This series of actions and omissions resulted in the resident receiving a medication to which they had a documented allergy, without appropriate review or notification.