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F0760
D

Medication Error: Eye Drops Administered to Wrong Eye

Laguna Hills, California Survey Completed on 05-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A registered nurse (RN) administered ciprofloxacin 0.3% antibiotic eye drops to the wrong eye of a resident who had a documented left eye infection. The medication administration record (MAR) and the medication label both indicated that the drops were to be instilled in the resident's left eye. During a medication pass observation, the RN was seen preparing and then administering the eye drop to the resident's right eye instead of the left as ordered. Upon review of the MAR and interview with the RN, it was confirmed that the order specified administration to the left eye for a left eye infection. The RN acknowledged the error after reviewing the order and the MAR. The resident also confirmed that the eye drop was given in the right eye and that the infection was in the left eye. This event constitutes a significant medication error as the medication was not administered as prescribed by the physician.

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