Failure to Provide Ordered Glaucoma Medication Due to Unavailability
Penalty
Summary
Facility staff failed to ensure that a resident received Latanoprost eye drops for glaucoma as ordered by the physician. The medication order, active since 2/14/24, required the drops to be administered at bedtime in both eyes. Clinical record review and interviews revealed that the resident did not receive the eye drops on multiple occasions, specifically on 1/16/25, 3/2/25, and 3/4/25, due to the medication not being available. Documentation indicated that the drops were reordered or that the pharmacy was contacted, but the medication was still not administered as prescribed. Interviews with two LPNs indicated that medication unavailability could be due to staff not ordering the medication or agency staff being unaware of overstock supplies stored in the medication room refrigerator. Facility policy required nurses to notify the provider and discuss alternatives or activate backup pharmacy procedures when medications were unavailable. Despite these policies, the resident's medication was not consistently available or administered as ordered, and the issue was brought to the attention of the facility administrator and DON.