Medication Error Rate Exceeded Due to Improper Ophthalmic Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors in 34 opportunities, resulting in an 11.76% error rate. The deficiency involved one resident who was admitted with diagnoses including respiratory failure, malnutrition, embolism of the right upper extremity and bilateral lower extremities, anemia, and hypotension, and who had moderate cognitive impairment and required substantial assistance with activities of daily living. The resident’s March physician orders included multiple ophthalmic medications: Brinzolamide 1% eye drops ordered as one drop twice a day without specifying which eye(s); Brimonidine 0.2% eye drops ordered as one drop in each eye twice a day; Atropine 1% eye drops ordered as one drop in the right eye; and Prednisolone Acetate 1% eye drops ordered for the right eye once daily. During observed medication administration, an LPN prepared the resident’s morning eye medications and then administered Atropine, Prednisolone, Brimonidine, and Brinzolamide in both eyes in rapid succession, without waiting the required interval between different eye drops. The LPN confirmed she did not wait five minutes between administering the eye drops, despite facility policy and manufacturer instructions requiring a waiting period between multiple ophthalmic products. She also acknowledged administering Atropine, Prednisolone, and Brinzolamide in both eyes because the resident requested drops in both eyes, even though the orders for Atropine and Prednisolone specified the right eye only and the Brinzolamide order lacked clarification regarding which eye(s) to treat. The Brinzolamide order was not clarified with the physician, contrary to facility policy requiring clarification of incomplete or questionable medication orders. Manufacturer instructions for all four medications specified waiting at least five minutes between drops (and ten minutes for Brinzolamide when used with another eye medication), which was not followed.
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