Failure to Update Eye Drop Administration per Ophthalmologist Recommendation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow up on an ophthalmologist's recommendation to increase the administration of Refresh Optive Mega-3 Ophthalmic Solution from two times per day to four times per day. The recommendation was documented in a consultation report and reviewed and accepted by the facility provider, as indicated by their initials. However, the physician order for the eye drops remained at two times per day, and the medication administration records showed that the resident continued to receive the drops only twice daily. The resident involved had a history of Myasthenia Gravis, dementia, bilateral ectropion, and recurrent conjunctivitis. During an observation, the resident was noted to have red, watery lower eyelids and a yellow crusty substance on the left upper lid. Interviews with staff confirmed that the process for updating the medication order after a consultant's recommendation was not followed, resulting in the resident not receiving the increased frequency of eye drops as recommended by the ophthalmologist.