Failure to Timely Administer Ordered Antibiotics for Eye Infection
Penalty
Summary
A resident with intact cognition and diagnoses of cerebral palsy and elevated white blood count developed symptoms of an acute right eye infection, including redness, swelling, pain, and discharge. During a telemedicine visit, the provider ordered both oral and ophthalmic antibiotics to be started immediately due to concerns for preseptal cellulitis and conjunctivitis. The provider's orders specified that the medications should be started the same day, and nursing staff were instructed to check the emergency kit for the required eye drops and to monitor the resident for worsening symptoms. Despite these orders, the resident did not receive the prescribed oral or ophthalmic antibiotics on the day they were ordered. Medication administration records showed that both medications were not started until the following day, with missed doses documented for the initial day. Interviews with family members, the resident, and multiple staff confirmed that the medications were not administered as ordered, and the delay was not communicated to the resident or their representative. Nursing staff and leadership acknowledged that this constituted a medication error, as provider orders were not followed and the required medications were not made available or administered as directed. Facility policy required that medications be administered according to provider orders and that any medication errors be documented, assessed, and reported. However, the Director of Nursing was not aware of the error until it was identified by the surveyor, and there was inconsistency in the documentation and reporting process. The facility's medication error policy and forms did not clearly specify requirements for resident or representative notification or documentation of resident assessment following a medication error.