Failure to Follow Physician Orders for Ophthalmic Medication Administration
Penalty
Summary
The facility failed to ensure that physician orders for ophthalmic medication administration were followed for one resident with visual impairment and multiple health conditions, including traumatic brain injury, respiratory failure, malnutrition, and depression. The resident's care plan required licensed nurses to administer eye medications as ordered by the provider. The medication administration record showed orders for two different ophthalmic medications: carboxymethylcellulose sodium eye drops to be administered four times daily with a five-minute interval before any other eye drop, and erythromycin ophthalmic ointment to be administered four times daily, with a requirement to separate its administration from the eye drops by 60 minutes. Despite these specific instructions, the medication administration records did not show that the required 60-minute interval between the two eye medications was observed. Observation and interviews confirmed that the licensed nurses administered both eye medications at the same time, contrary to the provider's orders. Both the resident and staff, including the LPN/Unit Supervisor and the Director of Nursing, acknowledged that the medications were not spaced as directed, and that the expectation was for nurses to follow the provider's orders regarding medication timing.