Allergic Resident Prescribed Contraindicated Antibiotic
Penalty
Summary
A resident with a documented allergy to Doxycycline, causing shortness of breath, was prescribed this medication despite the allergy being clearly listed in multiple parts of the medical record. The hospital after-care summary and the allergy section on the resident’s EMR banner both identified Doxycycline as an allergen. On 1/19/2026, after the resident tested positive for an infectious disease, a nurse contacted the physician via text message about the positive test result without having the EMR open to review allergies. The physician responded by ordering Doxycycline 100 mg twice daily for seven days, and the nurse transcribed this as a telephone order in the EMR. The nurse later stated she did not recall any allergy alert appearing when she entered the order. The physician reported he was unaware of the resident’s Doxycycline allergy and did not have access to the EMR, stating that nursing staff typically inform him of allergies. Another nurse explained that allergies are displayed beneath the resident’s name in the EMR and that an alert appears when a contraindicated medication is entered. The resident’s Guardian discovered the Doxycycline order while reviewing the MAR and notified the facility of the known allergy. The DON stated that nurses are expected to have the EMR open when contacting physicians so they can review allergies, and the Administrator acknowledged that the physician prescribed a medication to which the resident was allergic and that the nurse did not inform the physician of the allergy when the medication was prescribed.
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