Failure to Administer and Document Ordered Eye Drops
Penalty
Summary
The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with multiple diagnoses, including dry eye syndrome, anxiety, dementia, and quadriplegia. The resident was ordered to receive 0.5% Carboxymethylcellulose Ophthalmic Solution in both eyes at bedtime, but three scheduled doses were not administered as documented in the Medication Administration Record (MAR). There was no documentation in the progress notes or risk management reports explaining the missed doses, and no Medication Error Reports were completed for these omissions. Interviews revealed that medication aides did not use all available resources to obtain the eye drops, despite the medication being available in other medication carts and the medication room. The aides failed to notify the appropriate nursing staff or document the reasons for the missed doses, as required by facility policy. The resident reported not receiving the eye drops for several days and experienced mild irritation and burning in her eyes as a result. The Director of Nursing confirmed that the missed doses were not properly documented and that the process for obtaining over-the-counter medications was not followed.