Agency RN Administers Ear Drops into Resident’s Eye Without Documented Med Pass Competency
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in medication administration when a nurse administered an ear medication into a resident’s eye, constituting a significant medication error. The resident involved had multiple medical conditions, including metabolic encephalopathy, dependence on dialysis, type 2 diabetes mellitus, end-stage renal disease, cerebrovascular accident, dysphonia, and required assistance with personal care. The resident also had documented sensory impairments, including blindness in the right eye, deafness in the left ear, moderate hearing difficulty, and severely impaired vision, while remaining cognitively intact with a BIMS score of 15. Physician orders for this resident included Debrox (carbamide peroxide) 6.5% ear drops to be instilled in the right ear twice daily for four days starting on 06/10/25, and later, artificial tears ophthalmic solution to be instilled in the right eye three times daily starting on 06/12/25. Review of the June 2025 MAR showed Debrox was administered on 06/10/25 and 06/11/25, and that there were no eye medication or treatment orders scheduled before 06/12/25 at 9:00 AM. Despite this, on 06/11/25 the assigned RN reported that, after the resident requested medication, she mistakenly instilled an ear drop into the resident’s right eye, after which the resident immediately reported stinging in the eye. The incident was reported internally as a medication given via the wrong route, and facility investigation documents confirmed that the RN had administered an ear drop into the resident’s eye. Interviews with supervisory staff revealed that while the facility had a competency checklist for new and agency nurses and previously conducted medication pass audits, there was no documentation of medication administration competency checks or med pass observations for the RN involved after her initial orientation. The DON confirmed that the nurse was an agency RN and that no additional medication administration training or documented competency assessments were found for her following orientation, indicating a failure to ensure that the nurse possessed and demonstrated the necessary competencies and skills to safely administer medications to the resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.