Failure to Follow Physician's Order for Eye Drop Administration
Penalty
Summary
The facility failed to follow a physician's order for the administration of eye drops for one resident with severe cognitive impairment and chronic eye conditions, including ectropion and chronic blepharitis. The resident was observed with red eyes and yellow/white matter on the lower lids, and was seen rubbing his eyes. The physician's order specified Systane Complete Ophthalmic Solution, one drop to each eye twice daily, but only Ketotifen Fumarate eye drops were available and administered. The LPN stated that Ketotifen was being used in place of Systane, believing them to be the same, although the pharmacist later clarified that these medications serve different purposes and are not interchangeable. A review of the medication cart confirmed that only Ketotifen eye drops were present for the resident, with no Systane available. The pharmacist also noted that Ketotifen was not on the resident's order profile and that any substitution would require a physician's order and pharmacy notification, which had not occurred. The facility's policy requires that physician orders and prescriptions match and that any discrepancies be resolved with a valid prescription, but this protocol was not followed in this case.