Failure to Administer Prescribed Ophthalmic Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of Alzheimer's disease, dementia, central corneal ulcer, and conjunctivitis did not receive prescribed ophthalmic medication as ordered by the consulting ophthalmologist. The resident was evaluated by an ophthalmologist, who documented a treatment plan that included continuing polymyxin-trimethoprim eye drops four times daily to the left eye, in addition to starting erythromycin ointment. Despite this clear directive, the facility discontinued the polymyxin-trimethoprim eye drops on the same day as the ophthalmology consult, rather than continuing them for the full prescribed duration. Review of the medication administration record (MAR) showed that the eye drops were administered as ordered for several days but were stopped prematurely, with the discontinue date set before the end of the prescribed course. Nursing notes and order documentation confirmed that the medication was discontinued after the ophthalmology appointment, and the resident did not receive the eye drops after that point, contrary to the physician's orders. The error was later identified and documented as a medication incident, with the facility noting that the medication was discontinued when it should have been continued. Interviews with nursing staff revealed inconsistencies and a lack of clarity regarding the process for handling new or continued orders following a resident's return from a consultation appointment. Staff described varying procedures for transcribing and clarifying orders, and were unable to explain why the eye drops were discontinued despite the physician's explicit instructions to continue them. The deficiency was identified through record review, staff interviews, and confirmation that the resident did not receive the ordered medication as required.