Failure to Care Plan Antibiotic Eye Drops for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's use of polymyxin b-trimethoprim ophthalmic solution prescribed for an eye infection. The resident, an elderly female with dementia and severely impaired cognition, was admitted and readmitted to the facility with a diagnosis of dementia and had adequate vision according to her most recent MDS assessment. Physician orders indicated she was to receive antibiotic eye drops three times daily for seven days, and the medication administration record confirmed that the drops were administered as ordered. Despite the administration of the antibiotic eye drops, the resident's care plan did not include any interventions or monitoring related to the use of this medication. Observations showed the resident with pink and irritated eyes, and she was unable to confirm receipt of the eye drops due to confusion. Interviews with facility staff, including the LVN, MDS nurse, ADON, DON, and Administrator, revealed that responsibility for care planning new antibiotics was assigned to the ADON, with backup from the IDT and DON. However, the care plan for the antibiotic eye drops was missed, reportedly due to the ADON's absence and a disruption in the facility's usual morning meeting routine. Staff acknowledged that the lack of a care plan for the antibiotic eye drops could result in staff not being aware of necessary assessments, follow-up, or interventions, and that the omission was an oversight. The facility's policy requires comprehensive care plans for all resident needs, including new medications, but this was not followed in this instance.