Failure to Administer Ordered Treatments and Medications
Penalty
Summary
A resident with a history of hereditary syndrome of bilateral lacrimal glands, dry eye disorder, and malignant melanoma of the right upper eyelid did not receive prescribed treatments during a specific shift. The resident was cognitively intact, required assistance with toileting, and was independent with eating. Physician orders included administration of artificial tears to both eyes twice daily and a specific wound care regimen for the right leg. On the evening in question, the resident reported not receiving either the artificial tears or the wound care treatment, despite using the call bell and being told someone would return, which did not occur. The resident subsequently reported the missed care to the next shift, at which point the wound care was completed, but the eye drops were not administered as the nurse was unaware they had been missed. Documentation on the Medication Administration Record (MAR) indicated that the treatments had been provided by the LPN assigned to the earlier shift, but interviews and physical evidence (the unchanged dressing) confirmed the care was not performed as ordered. The facility's policy required licensed nurses to perform dressing changes as ordered by the physician.