Failure to Verify Medication Allergy Prior to Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to verify a resident's documented medication allergy prior to administering a new medication. The resident, who had a history of chronic respiratory failure, chronic obstructive pulmonary disease, type 2 diabetes with chronic kidney disease, and recent fractures, was admitted with a known allergy to gabapentin, which caused altered mental status. Despite this documented allergy, the LPN contacted the on-call physician to request medication for neuropathy and received a verbal order for gabapentin. The LPN did not check the resident's allergy list nor inform the physician of any allergies before administering the medication. The medication was pulled from the emergency box and given to the resident without verifying contraindications. The error was discovered when the resident's daughter was notified of the new medication and reminded the LPN of the allergy. The LPN acknowledged not following procedures, failing to check allergies, and not communicating the allergy to the physician prior to administration. This incident was confirmed through record review, staff interviews, and policy review.