Failure to Provide Ordered Ophthalmic Medication
Penalty
Summary
The facility failed to provide a resident with Refresh Liquigel Ophthalmic Gel 1% as ordered by the physician for dry eyes at bedtime. The resident, who was admitted with diagnoses including paraplegia and required substantial to maximal assistance with activities of daily living, reported not receiving the prescribed eye drops at night. Upon review, it was found that the medication was not present in the medication cart or the facility's house supply closet. Nursing staff confirmed the absence of the medication and indicated there was no record of pharmacy delivery receipts for the eye drops. Further investigation revealed that the pharmacy had not processed the order for the Refresh eye drops until the day of the survey, as the pharmacy does not automatically provide over-the-counter medications unless specifically requested by the facility. There was no documentation that the facility had contacted the pharmacy regarding the missing medication. According to facility policy, nursing staff are responsible for ensuring residents have a sufficient supply of prescribed medications and for communicating with the pharmacy if medications are unavailable. This lapse resulted in the resident not receiving the prescribed treatment for dry eyes.