Allergy to Acetaminophen Overlooked When Prescribing Pain Medication
Penalty
Summary
The deficiency involves a resident with multiple diagnoses, including cerebral infarction with resulting hemiplegia and hemiparesis, conversion disorder with seizures or convulsions, anxiety disorder, borderline personality disorder, and vascular dementia, who was severely cognitively impaired and dependent on staff for all ADLs. Clinical record review showed that this resident’s allergy to acetaminophen was documented in progress notes on several occasions shortly after admission. Despite this, a physician progress note later documented the same allergy list, including acetaminophen and eggs, and in the same entry ordered scheduled Tylenol (acetaminophen) for pain management, along with continuation of tramadol and an increased dose frequency of gabapentin. The resident’s daughter, who was the MPOA, reported that the facility’s medical director prescribed acetaminophen despite the known allergy. During interviews, the medical director stated that it was his practice to complete a chart review and obtain and review a resident’s history before assessment, but on the date in question he was covering for another physician, the resident was experiencing discomfort, and he prescribed acetaminophen. He acknowledged that he missed the documented allergy and stated that nursing staff and the pharmacy also did not identify the error. Facility leadership confirmed that the medication error was not identified and documented at the time it occurred and that the issue only came to their attention months later when the resident’s daughter formally reported the incident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.