F0760

H

Allergy Documentation Failure Leads to Significant Medication Error and Allergic Reaction

Bastrop, Texas Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically related to incomplete documentation and verification of medication allergies at admission. The resident was an elderly female with severe cognitive impairment (BIMS score of 6) and multiple diagnoses including a displaced comminuted fracture of the left tibia, coronary artery disease, hyperlipidemia, and unspecified dementia. Hospital discharge records and a facility resident evaluation uploaded to the electronic file on the day prior to admission clearly listed severe allergies to penicillins, sulfonamide (sulfa) antibiotics, azithromycin, and clindamycin, with reactions of swelling and rash. However, when the former DON entered allergy information into the electronic medical record, only penicillin, clindamycin, and azithromycin were added on the day of admission; sulfa antibiotics and Bactrim were not entered until several days later, after the adverse reaction occurred.

The admission process and responsibility for entering and verifying orders and allergies were fragmented among multiple nurses. The former DON stated she began entering the allergy information but stopped when state surveyors arrived for an investigation and then passed the task to another nurse, while a different LVN was the admitting nurse. One LVN reported only completing the second page of the admission checklist and stated the DON completed the first page, which included admitting medication orders and allergy information. Another LVN denied participating in the admission at all. Staff interviews showed confusion about who was responsible for completing the admission process, entering allergies into the EMR, and communicating clinical information and allergies to the NP. The NP stated that allergies are normally placed in the computer files and communicated by the nurse, and that she did not review the full chart within the first 24 hours of admission.

Due to the incomplete allergy profile, the NP ordered Bactrim DS (sulfamethoxazole-trimethoprim) for cellulitis of the resident’s left lower extremity, and the medication was administered a total of 12 times over several days. During this period, the resident developed a rash that was first noted as red spots on the back of the neck and back, later described as erythema and inflamed patches/hives with pruritus on the arms, thighs, back, and stomach, which worsened over time. The resident’s representative observed hives and a rash covering the resident’s body and questioned staff about possible causes. Nursing staff initially considered petechiae and possible reaction to soap or food, and were unaware of a Bactrim or sulfa allergy because it was not listed in the EMR at that time. After the NP was informed that the rash appeared more consistent with an adverse reaction, she reviewed the hospital records, identified the documented sulfa allergy, and discontinued the antibiotic. The NP reported that when she informed the DON, the DON acknowledged not having entered all of the allergies. The facility’s own medication administration policy required checking for drug allergies as part of the “10 Rights” of medication administration, but this was not effectively carried out, resulting in the resident receiving a medication to which she had a known allergy and developing a significant rash over her body.

The administrator confirmed that the admitting nurse was responsible for entering new resident information, including discharge orders and diagnoses, into the EMR and for communicating all clinical information to the physician and NP. He acknowledged that the allergy information for this resident was missed and not accurately transcribed, and that the former DON failed to complete the allergy portion of the ADT process. Multiple staff, including LVNs and the NP, recognized that the resident’s allergies were present on the hospital discharge paperwork but were not properly entered into the EMR or communicated, and that this failure led to the administration of Bactrim despite a known sulfa allergy. The facility’s failure to have clear processes and accountability for accurate verification and reconciliation of physician orders and allergies upon admission directly contributed to the significant medication error and the resident’s allergic reaction.