Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that the prescribed eye drops for one resident, identified as Resident 100, were administered as ordered by the ophthalmologist. Resident 100, who was admitted with diagnoses including respiratory failure, epilepsy, and polycystic kidney disease, was found to have glaucoma and age-related nuclear cataracts in both eyes. The ophthalmologist prescribed Latanoprost and Cosopt eye drops to manage these conditions. However, the orders for these medications were not carried out, as confirmed during an interview and record review with a registered nurse (RN 1). The nurse acknowledged that the orders were faxed to the facility but could not locate any documentation of clarification from the physician, and the medications were not initiated. The facility's policy and procedure for telephone orders, dated May 2018, outlines the steps to reduce errors in verbal or telephone communication of physician orders. This includes documenting the order immediately on the prescriber order form with specific details such as date, time, patient name, drug name, strength, dose, frequency, route, quantity, duration, prescriber's name, and recipient's signature. Despite these guidelines, the failure to administer the prescribed eye drops was identified, which had the potential to worsen Resident 100's eye conditions.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/10/25, the Quality Assurance (QA) Nurse called Resident 100 ophthalmologist office to clarify, eyedrop order. The order was clarified to Brimonidine 0.2% (1) drop to both eyes two times a day, Cosopt 0.2% (1) drop to both eyes two times a day, & Latanaprost 0.005% (1) drop to both eyes at hour of sleep. The order was noted and carried out. Resident 100 had no negative outcomes as a result of this deficient practice. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/25/25, the Director of Nursing (DON)/designee conducted an audit on residents who went to an appointment within the past 30 days, to ensure orders from such appointments were noted and carried out. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, DON in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN) on the facility policy and procedure titled, "Telephone Orders for Medication," with emphasis on reducing errors associated with misinterpreted verbal or telephone communication of physician orders by the receiver documenting the order immediately on the prescriber order form including the date and time order is received; patient name; drug name; strength, dose, frequency; route; quantity and/or duration; name of prescriber and the signature of the recipient. The DON/designee will conduct an audit of orders received from resident appointments daily for five days, weekly for two weeks, and monthly thereafter to ensure physician orders received from resident appointments are noted and carried out. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/25/25, the Director of Nursing (DON)/designee conducted an audit on residents who went to an appointment within the past 30 days, to ensure orders from such appointments were noted and carried out. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/24/25, DON in-serviced Nursing Staff, including but not limited to Licensed Vocational Nurses (LVN) and Registered Nurses (RN) on the facility policy and procedure titled, "Telephone Orders for Medication," with emphasis on reducing errors associated with misinterpreted verbal or telephone communication of physician orders by the receiver documenting the order immediately on the prescriber order form including the date and time order is received; patient name; drug name; strength, dose, frequency; route; quantity and/or duration; name of prescriber and the signature of the recipient. The DON/designee will conduct an audit of orders received from resident appointments daily for five days, weekly for two weeks, and monthly thereafter to ensure physician orders received from resident appointments are noted and carried out. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orders received from residents' appointments for three months or until compliance is met.