F0755

D

Medication Listed as Allergy Administered Despite Multiple Allergy Alerts

Mount Pleasant, Texas Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure accurate medication administration and adherence to documented drug allergies for one resident. The resident was admitted with diagnoses including traumatic brain injury, diabetes, and muscle weakness, and had a clearly documented allergy to Metformin on the face sheet, physician orders, care plan, hospital records, and the December MAR. Despite this, there was a physician order for Metformin HCL 500 mg by mouth twice daily starting on 12/19/25, and the medication was administered multiple times. The admission MDS showed the resident had moderately impaired cognition with a BIMS score of 11 but was able to understand and be understood.

Record review showed that Metformin was documented as an allergy in multiple parts of the medical record, including the face sheet, physician orders, care plan, hospital records, and MAR. The MAR for December indicated that LVN A administered an evening dose of Metformin on 12/19/25, MA B administered morning doses on 12/20/25, 12/21/25, and 12/22/25, and MA C administered evening doses on 12/20/25 and 12/21/25. A nursing progress note entered by the ADON on 12/19/25 at 8:46 p.m. documented that the system had identified a possible drug allergy for the Metformin order, but there was no documentation at that time that the allergy was clarified with the ordering provider or with the resident before the medication was administered.

Interviews with staff revealed that LVN A recalled giving the initial dose of Metformin but could not remember if it was listed as an allergy or whether an electronic warning appeared. LVN A stated she discussed allergies with the resident, who denied having allergies she could think of, and the nurse did not know when the Metformin allergy was entered into the record. MA B confirmed administering Metformin and stated it was not on the allergy list she saw and that she was unaware of the allergy, adding that if it had been listed, the system should have warned her or a nurse should have informed her. The ADON and DON both acknowledged that Metformin was already listed as an allergy in the electronic medical record when the provider wanted to restart it, and the DON stated she would have expected the ADON to document the conversation with the resident clarifying that the prior issue with Metformin was stomach upset. The Administrator stated he expected nurses to follow physician orders and to document any clarifying conversations about allergies. The survey finding concluded that the facility failed to provide pharmaceutical services and procedures that assure accurate administration of drugs and biologicals when staff administered a medication listed as an allergy for this resident.

Family interviews further confirmed that Metformin had been listed as an allergy for the resident and that the family had been told by the ADON that the resident did not have a reaction when it was given. The family member reported that the resident had not taken Metformin in years and did not know why it was administered again, and that the system had alerted the facility to the allergy. The facility’s admission/readmission policy required notification of applicable allergies to appropriate departments, but the documented allergy to Metformin did not prevent the medication from being ordered and administered on multiple occasions before it was placed on hold on 12/22/25 and discontinued on 12/23/25. The surveyors determined that this failure could place residents at risk for inaccurate drug administration.