Failure to Reconcile Medication Orders Leads to Incorrect Eye Drop Administration
Penalty
Summary
The facility failed to properly reconcile a resident's medication orders upon readmission, resulting in the resident not receiving prescribed eye drops as ordered by the physician. Specifically, the resident, who had a complex medical history including end stage renal disease, kidney transplant, congestive heart failure, and glaucoma, was supposed to receive Brimonidine Tartrate Ophthalmic Solution 0.2% one drop in each eye twice daily. Prior to hospitalization, this was the established order, and the hospital after visit summary (AVS) also indicated continuation of this regimen. However, upon readmission, the facility entered an order for the medication to be administered only once daily, and this was how it was given from 04/01/25 to 04/09/25. Interviews with the resident and an LPN confirmed the discrepancy between the intended twice-daily dosing and the once-daily administration. The resident reported awareness of the change and expressed concern that the facility was not following the correct regimen. The LPN acknowledged that the AVS contained conflicting instructions but that the check marks for morning and evening administration indicated the medication should have continued twice daily. Facility policy and the nurse admission checklist required verification and reconciliation of orders with the physician and pharmacy, but this process was not properly followed, resulting in the medication error.