F0755

D

Failure to Provide and Document Ordered Ophthalmic Medications

Buena Park, California Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The facility failed to provide ordered ophthalmic medications for a resident and did not ensure timely administration or appropriate documentation when doses were missed. The resident, who had glaucoma and no capacity to understand or make decisions, had physician orders for Refresh Plus eye lubricant every two hours for dry eyes and ocular surface irritation, Timoptic (timolol) twice daily for uncontrolled primary open angle glaucoma, and Lumify (brimonidine tartrate) twice daily for ocular hyperemia. Review of the MAR showed multiple missed doses of these medications. On one date, Refresh Plus was coded as held and as not given due to vitals being outside parameters, but the progress notes did not document the reason or specify what parameters were not met. On subsequent dates, Refresh Plus was not administered numerous times over two days, with MAR notes indicating the facility was awaiting medication from the pharmacy.

Further review showed that Timoptic was not administered at scheduled times on two separate dates, with one entry lacking any documented reason and another indicating the facility was awaiting delivery. Lumify was also not administered at a scheduled time, and nursing notes documented multiple follow-up calls to the pharmacy, which reported it did not have Lumify in stock. There was no documentation that the physician was notified of the multiple missed doses of these ordered medications. During interviews, RN 1 confirmed that charge nurses were responsible for requesting refills five days before medications ran out and acknowledged that the physician should have been informed when medications were not administered as ordered. The DON and Administrator were informed of and acknowledged these findings.