Glaucoma Eye Drops Inappropriately Held Without Orders, Leading to Prolonged Missed Doses
Summary
The deficiency involves a resident with bilateral primary open-angle glaucoma whose prescribed glaucoma eye drops were placed on hold without a physician’s order, resulting in numerous missed doses over an extended period. The resident, an older female with severe stage bilateral glaucoma and moderately impaired vision, had active diagnoses of unspecified open-angle glaucoma and used corrective lenses. Her care plan included administration of glaucoma medications (Latanoprost 0.005% once daily and Dorzolamide 2% twice daily) as ordered to relieve or minimize ocular pressure. During a night-shift medication cart audit, an ADON identified that the resident’s glaucoma eye drops were expired, removed them from the cart, and unilaterally placed both medications on hold in the electronic MAR without obtaining a physician’s order, documenting that the medications were on hold pending refill from hospice pharmacy. Following this action, the resident’s Latanoprost was on hold for a period during which 25 doses were missed, and Dorzolamide was on hold for a longer period during which 47 doses were missed. Multiple nurses, including LVNs and the weekend RN supervisor, reported that they were told by the ADON that the medications were on hold due to expiration and pending delivery, and they assumed that appropriate physician orders and notifications had been obtained because the ADON had executed the hold. The hold orders were entered without a stop date, and there was no documentation that the physician, NP, hospice, pharmacy, or the resident’s family had been notified at the time the medications were placed on hold. Staff interviews indicated that the eye drops’ unavailability and hold status were mentioned intermittently in morning clinical meetings and 24-hour reports, but there was no effective follow-through to secure replacement medications or clarify orders, and the medications remained on hold for nearly a month. The resident herself noticed that she was not receiving her usual glaucoma eye drops and reported this to her family member. The family member later contacted facility staff and hospice, expressing concern about the interruption in therapy and lack of communication. Subsequent review of records and interviews confirmed that hospice did not cover the glaucoma medications and had not been previously notified of any change, that the facility pharmacy had delivered Dorzolamide earlier than staff realized, and that Latanoprost had not been requested for refill for an extended period. The physician and MD later reported they had not been notified when the medications were placed on hold, and the ophthalmology office confirmed the resident’s glaucoma was severe and that the prescribed drops were intended to keep intraocular pressure down and prevent further optic nerve damage. The facility’s internal investigation and staff statements consistently showed that the ADON placed the medications on hold without a physician’s order, failed to follow up to ensure timely reordering and delivery, and that floor nurses relied on the ADON’s actions and did not independently obtain orders or restart the medications, resulting in the resident missing a significant number of prescribed glaucoma medication doses. Additional interviews with the Interim DON, Clinical Services Director, pharmacy consultant, hospice nurse, and other staff further detailed the sequence of inactions that led to the prolonged interruption of therapy. The Interim DON and CSD stated that any medication placed on hold should have an associated physician order, with clear start/stop parameters, and should be tracked via reports and discussed in clinical meetings until resolved. They reported that in this case, the hold orders for the glaucoma drops lacked a physician order and stop date, and the issue was not consistently or effectively addressed in daily clinical oversight. The hospice nurse reported learning of the discontinuation only after a family call and stated that the ADON acknowledged placing the drops on hold and forgetting to follow up. The MD and pharmacy consultant explained that failure to receive glaucoma medications could allow intraocular pressure to increase and glaucoma to progress, and the ophthalmology assistant emphasized that once vision loss occurs from glaucoma, it is permanent. Collectively, the documentation and interviews show that the resident was not kept free from significant medication errors because her essential glaucoma medications were inappropriately held without medical authorization and without timely follow-up, leading to a prolonged period in which she did not receive the prescribed therapy. Throughout this period, multiple staff members, including LVNs, the weekend RN supervisor, and a medication aide, were aware that the eye drops were on hold and unavailable, but they either believed the ADON had already obtained necessary orders or lacked authority to change the hold status. The resident’s family member and hospice nurse ultimately brought the issue to higher-level attention after discovering that the resident had gone without her glaucoma medications for nearly a month. Interviews with the Administrator and Interim DON confirmed that they were not promptly informed when the family first raised concerns over a weekend, and that the ADON, who was responsible for pharmacy systems and medication availability, did not ensure that the medications were reordered, delivered, and restarted. As a result, the resident missed dozens of doses of both Latanoprost and Dorzolamide, contrary to her care plan and physician’s original orders, constituting a significant medication error. The report also documents that the resident did not report pain, blurry vision, or noticeable vision loss during the period without eye drops, and that she continued to use glasses for near and far vision. However, clinical experts interviewed in the report noted that glaucoma is often asymptomatic, that increased intraocular pressure is not felt by the patient, and that progression of glaucoma and associated vision loss can occur over time without obvious symptoms. The facility’s own clinical leadership and external consultants characterized the interruption of glaucoma therapy as a serious concern, and the Clinical Services Director stated she would consider the situation a form of neglect. The deficiency is therefore based on the facility’s failure to ensure that the resident was free from significant medication errors by allowing her prescribed glaucoma medications to be held without proper authorization or follow-up, resulting in a prolonged lapse in treatment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to ensure residents were free from significant medication errors when one resident drank coffee containing another resident’s medications. The DON stated medications should always be observed during administration, but a CMA said they did not watch the resident take the meds and gave them in coffee without observing the resident drink it. The physician was notified and reviewed the medications involved.
Unattended Medication Left at Resident Bedside: A resident with severe cognitive impairment had a medication cup containing four tablets left unattended on the bedside table. An LPN stated she placed the medications there while getting juice and admitted this was against facility policy. RN and DON confirmed medications should not be left unattended at the bedside and that the action violated the facility’s medication administration P&P.
Missed Hydroxyurea Doses on Admission: A resident with thrombocytopenia, chronic myeloproliferative disease, and CML did not receive ordered Hydroxyurea on admission. The hospital discharge order called for Hydroxyurea 500 mg every other day, but the med was not entered promptly, pharmacy delivery was delayed, and the MAR showed the first documented dose was not given until several days later. The family member reported the resident missed his chemotherapy med for three days, and staff interviews showed uncertainty about who completed the admission med review and when the order was obtained.
Medication Error Caused Severe Bradycardia and Hospital Transfer: A severely cognitively impaired resident with sinus bradycardia received his scheduled AM meds and then was mistakenly given another resident's meds, including metoprolol succinate ER, amlodipine, tamsulosin, and donepezil. He became lethargic with HR in the 30s to 40s and BP 90/60, was sent to the hospital, and was diagnosed with severe symptomatic bradycardia, hypotension, and progression to complete heart block requiring epinephrine, atropine, and a dual-chamber pacemaker.
Missed Antiseizure Medication Doses: A resident with epilepsy and other significant diagnoses did not receive ordered Phenytoin doses because the bubble pack was empty and the medication was unavailable in the cart. An LPN reported missed doses, another LPN said she faxed the pharmacy more than once but did not follow up, and the DON acknowledged 19 missed doses. The pharmacist said only a 3-day supply had been delivered and the facility had not provided required physician clarification before the refill was issued. The resident later had seizure activity and was transferred to the hospital for further evaluation.
A facility failed to administer multiple ordered medications for three residents. One resident with seizure disorder, hypotension, and colon cancer missed repeated doses of seizure meds, midodrine, Depakote, and an antibiotic; a second resident with seizure disorder, diabetes, and HTN missed repeated doses of lamotrigine, levetiracetam ER, and pregabalin; and a third resident with diabetes and cellulitis missed ordered sliding-scale insulin doses, with blood glucose not monitored at the missed times. An LVN stated meds should be given as ordered, and the ADON and pharmacy consultant acknowledged the missed administrations.
Medication Administration Error
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents reviewed for medication administration. A policy stated medications are to be administered at the time they are prepared and the resident is to be observed taking them. The record showed that one resident drank coffee containing medications that belonged to another resident, and the medication administration record showed that the other resident received Rexulti 2 mg, buspirone HCl 10 mg, and alprazolam 0.5 mg. The DON stated medications should always be observed during administration to ensure the resident takes all of the medication and to prevent another resident from taking them. CMA #2 stated they did not watch the resident take the medications and gave the medications in coffee without observing the resident drink it. The physician stated they were notified that one resident had taken medications belonging to another resident and ordered the evening medications held, vital signs monitored, and assessments completed.
Unattended Medication Left at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were secured and administered according to its medication administration policy for one sampled resident. Resident 3 had diagnoses including encephalopathy and senile degeneration of the brain, and the MDS dated May 6, 2026, showed a BIMS score of 00, indicating severe cognitive impairment. During observation on July 2, 2026, a medication cup containing four tablets was found unattended on Resident 3’s bedside table in the resident’s room. When asked, Resident 3 stated she did not know whether the medication belonged to her and appeared confused. During the same observation, RN 1 confirmed the four tablets were left unattended on the bedside table and stated that it was against facility protocol to leave medication unattended at the bedside. RN 1 stated the medications likely had been left there by LVN 1 and should have remained under LVN 1’s direct supervision until administered. LVN 1 stated the tablets belonged to Resident 3 and admitted she had placed them on the bedside table while she went to obtain juice for the resident, acknowledging that leaving the medications unattended was a mistake and was not consistent with the facility’s medication administration policy. The DON reviewed the policy, which stated that medications are to remain secured when the medication nurse or aide is out of sight, and confirmed that leaving medications unattended on a bedside table violated facility policy and the expected standard of practice.
Missed Hydroxyurea Doses on Admission
Penalty
Summary
The facility failed to ensure that a resident with thrombocytopenia, chronic myeloproliferative disease, and chronic myeloid leukemia received Hydroxyurea as ordered upon admission. The resident was admitted with a hospital discharge instruction to start Hydroxyurea 500 mg, 1 capsule by mouth every other day, beginning on 4/24/26. A physician progress note on 4/24/26 documented that the resident was taking Hydroxyurea 500 mg once daily and stated that the medication list was reviewed and reconciled with the patient. The resident’s medication order was not entered into the facility’s order summary until 4/27/26, when a physician order for Hydroxyurea 500 mg every 48 hours was documented. That same evening, an RN documented that the oncologist called with the order, noted the order was already in place, and recorded that pharmacy was called to deliver the medication. The RN also documented that the resident’s family member said she could go to her pharmacy to get the medication, then later documented that the pharmacy reported the Hydroxyurea would be delivered that night and that the family member could not obtain it from the pharmacy. The MAR showed the resident received Hydroxyurea 500 mg by mouth on 4/29/26, and documentation indicated the medication was not administered on 4/27/26. In a telephone interview, the family member stated the resident missed his chemotherapy medication for three days while in the facility and that they gave him the medication after bringing the issue to staff’s attention. Interviews with nursing and administrative staff indicated uncertainty about who completed the medication review on admission and that the facility expected family members to bring chemotherapy medications from home, with the medication not being ordered from the pharmacy until after the oncologist was contacted.
Medication Error Resulted in Severe Bradycardia and Hospitalization
Penalty
Summary
The facility failed to prevent a significant medication error involving a severely cognitively impaired resident with diagnoses including Alzheimer's disease, sinus bradycardia, hypertension, diabetes, depression, and psychotic disorder with hallucinations. On the morning of the event, a Medication Aide administered the resident's scheduled medications, which included propranolol ER, quetiapine, donepezil, metformin ER, and citalopram. The aide then returned to the medication cart, prepared another resident's medications, and later gave those medications to the same resident in error. The medications mistakenly given to the resident included metoprolol succinate ER, tamsulosin, amlodipine, and donepezil, which were prescribed for another resident. Approximately 30 minutes later, the Medication Aide realized the error and reported it to the nurse. The resident was assessed and found to be lethargic with a heart rate in the 40s that dropped into the high 30s and a blood pressure of 90/60. EMS was contacted and transported the resident to the hospital for evaluation. Hospital records documented severe symptomatic bradycardia and hypotension secondary to an unintentional medication overdose with beta blockers and amlodipine. The resident's ECG progressed from sinus bradycardia with second-degree AV block to complete heart block, and he required epinephrine infusion and atropine with limited response. He later underwent implantation of a dual-chamber pacemaker and returned to the facility after hospitalization. Interviews with the Medication Aide, nurse, NP, pharmacist, and Medical Director confirmed that the resident received both his own morning medications and another resident's medications, and that the medication error was associated with the resident's decline in heart rate and blood pressure.
Missed Antiseizure Medication Doses
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including epilepsy, hemiplegia, hemiparesis, and hypertension received Phenytoin as ordered. The physician’s order required Phenytoin 100 mg by mouth at 9:00 AM, 1:00 PM, and 5:00 PM for seizures, but the Medication Administration Record showed multiple missed doses from June 7 through June 17, 2026, totaling 19 doses. During interview, an LVN stated one dose was not given because the bubble pack was empty, and another LVN stated the medication was not in the bubble pack for a couple of days and that she faxed the order to the pharmacy more than once because the medication was not available in the medication cart. The DON reviewed the MAR and acknowledged the medication was not administered for eight days, totaling 19 doses, and stated medications must be available for residents and that the pharmacy is contacted immediately when they are not. The pharmacist stated only a three-day supply had been delivered and that the facility did not provide required clarification from the physician before June 18, 2026, so the pharmacy did not issue a refill until that date. The resident’s clinical record also documented seizure activity on June 17, 2026, with two petite mal seizures and a blood pressure of 162/111, after which the physician ordered transfer to the hospital for further evaluation.
Repeated Missed Medication Administrations
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for three sampled residents. Resident 1 had diagnoses including colon cancer, muscle weakness, seizure disorder, and hypotension, and the MDS indicated the resident’s cognition was not intact and the resident was unable to make decisions. The physician orders included Keppra, lacosamide, Depakote, midodrine, and metronidazole, but the MAR showed multiple missed doses of each medication across May 2026, including repeated missed evening doses of seizure medications, missed midodrine doses, missed Depakote doses, and missed metronidazole doses. Resident 2 had diagnoses including muscle weakness, seizure disorder, hypertension, diabetes, and a history of falls, and the MDS indicated cognition was intact. The physician orders included lamotrigine, levetiracetam ER, and pregabalin, but the MAR showed multiple missed doses of all three medications in May and June 2026. The missed doses included repeated omissions of the seizure medications and pregabalin at scheduled administration times. Resident 3 had diagnoses including cellulitis of both lower limbs, diabetes, and hypertension, and the MDS indicated cognition was intact. The physician order included insulin aspart by sliding scale before meals and at bedtime, but the MAR showed that blood glucose was not monitored and the insulin order was not administered on multiple occasions in June 2026. During interviews, an LVN stated medications should be administered as ordered, and the ADON acknowledged that the residents had multiple medications not administered as ordered. The pharmacy consultant stated antibiotics should be given as scheduled and completed, missing seizure medications increase the chance of seizure episodes, and the facility should follow physician orders for medication administration.
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