Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
A resident with diagnoses including diabetes, dementia, anxiety, open-angle glaucoma, and legal blindness was admitted to the facility with a physician's order for Bimatoprost eye drops to be administered in both eyes in the evening to manage intraocular pressure. Review of the Medication Administration Record (MAR) for June revealed that the resident did not receive the prescribed Bimatoprost medication on 22 separate days. The Director of Nursing (DON) confirmed that these doses were missed and acknowledged the medication was not administered as ordered. Further review of the resident's progress notes showed no documented evidence that the physician was notified about the missed doses of Bimatoprost. The DON stated there was no documentation of physician notification regarding the medication omission. According to the facility's policy and procedure for medication administration, all medications are to be administered as ordered, and the physician must be notified by telephone if a medication error occurs. Reference materials reviewed also indicated that failing to administer a medication and not notifying the healthcare provider constitutes a medication error.