Failure to Timely Administer Post-Operative Ophthalmic Medications
Penalty
Summary
The facility failed to ensure accurate acquiring, receiving, dispensing, and administering of prescribed ophthalmic medications for Resident #32 following cataract surgery. Resident #32, who had intact cognition and multiple medical diagnoses including macular degeneration and cataracts, underwent cataract surgery and received post-operative orders for Prednisone 1% ophthalmic drops once daily, Ketorolac Tromethamine 0.5% drops four times daily, and Moxifloxacin 0.5% drops three times daily to the left eye for specified durations. The resident reported he was to start eye drops two hours after surgery and had given the paperwork to staff. Review of the medication administration record showed that none of the ordered eye drops were administered on the afternoon and evening of the surgery date or the following morning. Interviews revealed multiple breakdowns in the medication process. The surgery office initially sent the prescriptions to the resident’s old pharmacy and later had them filled at the hospital pharmacy, with the lead nurse personally delivering the medications to the facility in the late afternoon. The DON stated the facility did not have the eye drops the night before and that the pharmacy was called to drop ship them the next morning. The resident later stated he had been told the drops were delivered around 4:00 p.m. the previous day but were not placed in the medication cart and could not be located. An LPN confirmed she had not administered the drops and was only going to do so once they were found. Another LPN verified the drops had been delivered the previous afternoon by the hospital pharmacy, but the staff member who received them placed them in the wrong medication cart, and the nurse on duty was unaware they had been delivered, resulting in the medications not being started as ordered until the following morning.
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