Failure to Provide Timely Eye Treatment per Physician Orders
Penalty
Summary
The facility failed to follow physician orders for eye treatments for one resident with complex regional pain syndrome and anxiety. Upon admission, the resident had a physician order for Optase (Glycerin) Comfort Dry Eye Solution to be applied twice daily. However, the medication was not available or on order from 7/2/25 through 7/10/25, and the resident did not receive the prescribed treatment during this period. Documentation shows that the resident repeatedly requested the eye drops, which increased their anxiety, and staff communicated with the pharmacy and the provider regarding the unavailability of the medication. On 7/7/25, a request was made to substitute the prescribed Optase with house stock Systane, and the physician approved this change. However, the new order for Systane was not implemented until 7/9/25, resulting in a delay in providing the necessary eye treatment. Staff interviews confirmed awareness of the medication shortage and the lack of a timely system to report or resolve missing medications. The delay in obtaining and administering the prescribed or substitute eye drops did not meet staff expectations and resulted in the resident's needs not being met as ordered.