Failure to Administer Eye Drops as Prescribed Following Cataract Surgery
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as prescribed for a resident following cataract surgery. Specifically, a male resident with a history of dementia, cystoid macular degeneration, and recent cataract surgeries was prescribed prednisolone eye drops for both eyes. The physician's prescription ordered one drop in the right eye twice daily and one drop in the left eye three times daily. However, the facility's physician order and subsequent medication administration records reflected that the resident received the drops in both eyes only twice daily, not adhering to the prescribed frequency for the left eye. Interviews with nursing staff and the Director of Nursing (DON) revealed confusion regarding the correct dosage and frequency of the eye drops. Staff indicated that they could not administer medications without a clear and complete physician's order and would seek clarification if orders were unclear. The DON acknowledged discrepancies between the written prescription and the order entered into the facility's system, noting uncertainty about whether multiple or conflicting orders had been received from different clinics. The resident was also described as resistant to providing post-visit orders, which contributed to the confusion. A review of the facility's medication administration policy confirmed that orders must be accurately implemented as written. Despite the error, the ophthalmic assistant from the prescribing clinic stated that the deviation in administration likely had minimal to no effect on the resident, as there was no evidence of inflammation or negative outcome documented. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the medication as prescribed during the specified period.