Failure to Provide Prescribed Eye Drops as Ordered
Penalty
Summary
The facility failed to ensure that the correct prescribed eye drops were available in the Sub-Acute Medication Cart according to the physician's orders for a resident. The resident, who had a history of respiratory failure, aphasia, dysphagia, and brain damage, was noted to have severely impaired cognitive skills and was dependent on staff for activities of daily living. The physician had ordered Refresh Tears Ophthalmic Solution 0.5% for the resident. During a medication administration observation, a nurse was found to be removing Polyvinyl Alcohol 1.4% eye drops from the medication cart, which did not match the physician's order and was not prescribed for the resident. The nurse stated that the correct eye drops had not been delivered by the pharmacy and acknowledged that the Polyvinyl Alcohol drops required physician clarification, as there was no order for them. The resident's eye drops were held, and the nurse indicated that the situation could result in a medication error. Facility policy requires that medication labels and orders be checked for accuracy prior to administration.