Failure to Verify Allergy Before Administering Hydrocortisone
Penalty
Summary
The facility failed to ensure that a resident with a documented cortisone allergy was protected from significant medication errors when hydrocortisone ointment was ordered and administered without verification of allergies. The resident’s face sheet showed admission with multiple serious diagnoses, including nontraumatic intracerebral hemorrhage, acute respiratory failure, quadriplegia, and type 2 diabetes. An allergy list dated 11/15/2024 documented a cortisone allergy with unknown severity. An MDS dated 11/24/2025 indicated the resident had severe cognitive impairment, was rarely or never understood by others, was dependent on staff for activities of daily living, and was at risk for pressure injuries. On 2/13/2026, a change of condition note documented bilateral groin moisture-associated skin damage, and the physician was notified and ordered hydrocortisone ointment to the affected area every shift. The order recap report showed hydrocortisone 2.5% ointment was ordered on 2/13/2026 and the MAR documented that the resident received hydrocortisone every shift on five occasions between 2/13/2026 and 2/15/2026. Email communication between an RN and the DON on 2/17/2026 indicated the RN failed to check the resident’s allergies when the hydrocortisone cream was ordered. In a telephone interview, an LVN stated she administered hydrocortisone as ordered but did not check the resident’s allergies prior to administration. The DON stated that, based on her review, three nurses administered hydrocortisone ointment without checking the documented allergies. The facility’s medication administration policy, revised 4/2019, required that resident allergies be checked and verified prior to administering medications.
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