Failure to Administer Ordered Medication After Known Food Allergy Exposure
Penalty
Summary
The facility failed to ensure services were provided in accordance with professional standards of quality by not following a physician’s order for a resident who had a known tomato allergy. The resident, admitted with dementia and with a documented tomato allergy of unknown severity in the electronic health record since June 2025, consumed food containing red tomato sauce. A nurse practitioner documented that the resident had eaten red tomato sauce despite the allergy and ordered a one-time dose of Reglan 10 mg with continued close monitoring for any signs and symptoms of allergic reaction. A corresponding physician’s order for Reglan 10 mg once was entered on the same date. Review of the Medication Administration Record for that month showed Reglan coded as “9” by an LPN, indicating to refer to progress notes. A progress note by the same LPN documented that the Reglan was pending delivery from the pharmacy, and there was no evidence in the record that the medication was ever administered or that the provider was notified that the ordered medication was not given. An inventory summary for the facility’s Pyxis automated dispensing machine showed that it routinely stocked at least three 5 mg Reglan tablets. In an interview, the LPN acknowledged that the Reglan was not administered and could not provide evidence of provider notification, and the Director of Nursing stated that Reglan is regularly stocked in the Pyxis and that she would have expected the medication to be administered as ordered and the provider notified and documentation completed if it was not.
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