Failure to Administer Physician-Ordered Eye Drops and Inadequate Documentation
Penalty
Summary
Facility staff failed to administer Latanoprost eye drops as ordered by the physician for a resident with glaucoma. The resident reported during an interview that he frequently did not receive his prescribed eye drops. Review of the clinical record and medication administration record (MAR) confirmed that the eye drops were not administered on two specific dates, with one date left blank on the MAR and the other marked as held, without any documentation explaining the omission. The physician's order for the eye drops had been active since February and remained so at the time of the survey. Interviews with the DON and two LPNs revealed that medication administration was inconsistent, particularly when medications were not available or when agency staff were unaware of where extra supplies were stored. The facility's policy required medications to be administered as ordered and documented immediately after administration, but this was not followed in the resident's case. No documentation was provided in the nursing progress notes to explain why the medication was not given, and the DON acknowledged that blanks on the MAR indicated the medication was not administered and should have been explained.