Unsupervised Resident Use and Improper Storage of Non-Ordered Eye Drops
Penalty
Summary
A lubricant eye drops solution was found stored on top of a resident's overbed table, which was brought in by a family member and used by the resident without a physician's order, self-administration assessment, or supervision. The resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including heart failure and kidney disease, reported using the eye drops as needed for her left eye. Multiple observations confirmed the eye drops remained at the bedside over two days, and the resident stated she had used them for years. The medication was not listed in the resident's electronic Medication Administration Record, which only included an order for a different ophthalmic solution. Licensed nursing staff, including an LVN, the ADON, and the DON, acknowledged during interviews that the eye drops should not have been stored at the bedside and that it was the responsibility of licensed nurses to ensure no medications from home were present at the bedside. The facility's policy required all drugs and biologicals to be stored in locked compartments, accessible only to authorized personnel. The failure to follow these procedures resulted in the resident having unsupervised access to and use of a medication not ordered by a physician.