Missed Glaucoma Medication Doses Due to Staff Miscommunication and Storage Oversight
Penalty
Summary
A resident with a diagnosis of glaucoma was admitted to the facility and had a physician's order for timolol maleate 0.5% eyedrops to be administered twice daily. Over the course of February and March, the resident missed 11 doses of the prescribed eyedrops. Nursing staff documented on the Medication Administration Record (MAR) that the medication was unavailable and that they were awaiting delivery from the pharmacy. Multiple nurses reported that the eyedrops were not on the medication cart and believed the medication had not been delivered, relying on information from other staff or their own assumptions. However, the pharmacy consultant confirmed that the medication had been delivered as scheduled with no gaps in delivery, and the medication was found stored in the medication refrigerator, where it was supposed to be kept. The resident, who was cognitively intact and had impaired vision due to glaucoma, reported to surveyors that she was not given her eyedrops and was told by nurses that the medication was being reordered. Interviews with nursing staff revealed a lack of awareness regarding the storage location of the medication, leading to repeated missed doses. The Assistant Director of Health Services confirmed that complaints were received from the resident and her family about missed doses, and upon investigation, the medication was located in the refrigerator where it had been delivered and stored.