Failure to Administer Glaucoma Eye Drops as Ordered and Honor Self-Administration Order
Penalty
Summary
The deficiency involves the facility’s failure to administer glaucoma eye drops as ordered by the physician and in accordance with the resident’s preferences and goals. The resident, who has multiple diagnoses including glaucoma, hemiplegia/hemiparesis, COPD, atrial fibrillation, type 2 diabetes, hypertension, and mild cognitive impairment (BIMS score 11), reported that she is supposed to receive dorzolamide 2% eye drops three times daily but has frequently missed doses, particularly at night and early morning. She stated that when she previously kept the eye drops at her bedside and self-administered them at approximately 5:00 a.m., 1:00 p.m., and 9:00 p.m., she did not miss doses, but the drops were taken away and she no longer knows why. She consistently expressed that she is capable of self-administering the drops and that not receiving them as ordered is her primary concern. Record review showed a physician order and MAR entry for dorzolamide 2% eye drops, one drop in both eyes three times a day for glaucoma, with a notation that the resident may keep the eye drops at bedside for self-administration per NP. The March MAR documented the early morning dose as “S” (sleeping) on 11 of 21 days, and the DON confirmed that “S” indicates the resident was sleeping and that the medication should be administered when the resident wakes up. The DON also stated that if a resident has an order to keep medication at bedside, it should be at bedside, and that this resident is allowed to have the eye drops at bedside and self-administer if she prefers. The attending physician stated he should have been notified that the resident was not receiving the medication as ordered and confirmed that the eye drops are intended to reduce intraocular pressure and should be given three times per day; if the resident is sleeping at the scheduled time, the drops should be administered as soon as she awakens rather than omitted. These interviews and records demonstrate that the ordered three-times-daily dosing and bedside self-administration option were not consistently implemented.
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.