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Based on medical record review, policy review, review of medication error records, and staff interview, the facility failed to follow their policy and administered medications to a patient with a listed allergy to the medication. This affected one patient, Patient #4, with the potential to affect all patients cared for in this facility.

Findings include:

The medical record for Patient #4 revealed an admission on 08/09/23 with a history of bipolar disorder associated with severe anxiety and insomnia. Admission notes stated this patient developed a pruritic (itchy) skin lesions two months ago. Twelve allergies were listed with Gabapentin being one.

Nursing notes dated 08/14/23 at 11:47 AM stated Patient #4 verbalized her itching was starting up with hydroxyzine given. Later on this patient yelled out from her room "I can't take this!" The registered nurse (RN), Staff F, called the medical nurse practitioner (NP) with orders received for Gabapentin 100 milligrams (mg) three times per day at 9:00 AM, 1:00 PM, and 9:00 PM. Nursing notes further revealed Patient #4 denied allergy to the medication even thought the medical record listed Gabapentin as an allergy.

The first dose of Gabapentin was administered on 08/14/23 at 11:06 AM and the second dose was given at 1:50 PM.. Patient #4 verbalized relief of pain and itching after lunch and was playing cards with other patients all afternoon. The NP, Staff D, was present and she discontinued the Gabapentin at 4:14 PM due to the history of being allergic to it.

Reviewed medication error records with Staff B on 10/26/23 at 4:45 PM revealed Patient #4 was listed in this report due to receiving a medication they were allergic to. An interview at this time with Staff B verified no follow up education was provided to staff regarding the error.

Review of the facility policy titled "Medication Orders," dated June 2020, revealed staff to write orders in the patient's medical record. The pharmacist will review every medication order to include contraindications and allergies.

Review of the facility policy titled "General Medication Administration," dated June 20202, instructs the medication nurse to check for allergies prior to administering all medications.

Interview on 10/27/23 at 5:15 PM Staff A and Staff B verified the facility did not follow their policy in regards to administering Gabapentin to Patient #4 who had an allergy to the ordered medications.