Failure to Administer Prescribed Ophthalmic Medication Due to Pharmacy Delay and Lack of Notification
Penalty
Summary
Licensed Nurses (LNs) failed to consistently administer prescribed eye drop medication to a resident diagnosed with glaucoma, as ordered by the physician. The resident was readmitted with a diagnosis that included glaucoma, and the physician's order specified the use of Latanoprost ophthalmic solution for both eyes. A review of the medication administration record (MAR) revealed that the resident did not receive the prescribed eye drops on several dates, and there was no documentation of administration for those days. During a joint review and interview, it was confirmed that the missed doses were due to a delay in the delivery of the medication from the pharmacy. The nurses' notes indicated the medication was not available, but the LNs did not notify the Director of Nursing (DON) or the Administrator (ADM) to expedite the delivery. The facility's policy provided did not address the requirement to follow physician's orders, contributing to the failure to ensure the resident received treatment and care in accordance with professional standards of practice.