Improper Eye Drop Administration and Medication Handling
Penalty
Summary
The facility failed to provide proper pharmaceutical services in the administration of eye drops to a resident with glaucoma and other significant medical conditions. During a medication pass, a medication aide did not pull down the lower eyelid before instilling the prescribed Latanoprost eye drops, contrary to facility policy and standard procedure. Additionally, the aide placed the medication cap with the inside facing down on an unclean nightstand surface, which was not disinfected prior to the procedure, and then replaced the cap onto the bottle after administration. The resident involved was an elderly female with a history of heart failure, fainting, glaucoma, and elevated blood pressure. She had severe cognitive impairment and required varying levels of staff assistance for activities of daily living. The resident's care plan noted impaired visual functioning and risk for decreased ADLs due to glaucoma, but did not specify interventions for medication administration as ordered by the physician. Observation revealed that the medication aide instilled the eye drops without forming a pouch by pulling down the lower eyelid, and the resident did not always receive the correct number of drops as ordered. The aide also failed to maintain the cleanliness of the medication cap, potentially contaminating the dropper. These actions were inconsistent with both the facility's policy and the aide's documented competency checklist, which required proper technique for eye drop administration.