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Based on observation, interview, and document review the hospital failed consistently adhere to its established policy for the safe administration of eyedrops. The investigation revealed proper compression techniques were not applied to minimize systemic absorption. This inconsistency demonstrates a failure to maintain the standards outlined in the hospital's medication safety protocols, potentially compromising patient safety and the effectiveness of the administered treatments.

Findings:

A review conducted on 08/21/24, of the hospital policy titled "Specific Medication Administration Procedures - Eyedrop Administration, Section 8.5," dated June 2015, highlighted the following guidelines for administering eyedrops: When applying the eyedrops, ensure that the patient's eye is closed. To reduce the systemic absorption of the medication, gently compress the tear duct, located at the inner corner or inner canthus of the eye, using one finger for one to two minutes. As an alternative method, the resident may be instructed to keep their eyes closed for approximately three minutes. These procedures are designed to optimize the administration of eyedrops and minimize potential side effects. Healthcare professionals should adhere to these guidelines to ensure safe and effective medication delivery.

During an observation in the Acute Psychiatric Hospital on 08/21/24, at 10:30 AM, LVN 1 administered Brimonidine 0.2% and Levobunolol 0.5% eye drops to Patient 1. However, after instilling the drops, the nurse did not use one finger to compress the tear duct, also known as the inner corner or inner canthus of the eye, for one to two minutes, which is recommended to reduce the systemic absorption of the medication. Additionally, the resident was not instructed to keep their eyes closed for approximately three minutes as an alternative method to minimize absorption. To ensure optimal administration of eye drops and reduce potential side effects, it is essential for healthcare professionals to follow proper techniques, such as gentle compression of the tear duct or instructing patients to keep their eyes closed for a recommended duration.

During an interview conducted on 08/21/24, at 10:45 AM, LVN 1 admitted that she had inadvertently forgotten to apply pressure with her finger to the tear duct while administering eye drops. LVN 1 expressed her intention to improve her technique and remain more vigilant in the future, acknowledging her oversight. This demonstrates her willingness to learn from the incident and ensure that proper medication administration protocols are followed for optimal patient care and safety.

Based on interviews and document reviews, it was determined that the hospital did not fulfill its obligation to conduct monthly unit inspections on all nursing stations. Evidence revealed that only one nursing station in each tower received a pharmacist inspection each month, leaving most nursing stations without a routine pharmacist inspection. This failure to consistently assess medication management practices across all nursing stations may pose potential risks to patient safety and raises concerns about the hospital's adherence to established guidelines and regulations.

Findings:

A review of the hospital policy dated December 2017, titled "Organizational Aspects - Consultant Pharmacist Services Provider Requirements, Section 1.2," the responsibilities of the consultant pharmacist encompass various activities. These duties include, but are not limited to, the monthly inspection of medication storage areas for proper storage, labeling of medications, cleanliness, and the removal of expired medications. This policy underscores the importance of regular assessments to ensure appropriate management of medications within the hospital setting.

During an interview on 8/21/24, at 2:00 PM, Registered Pharmacist 1 explained that they conduct unit inspections on one nursing station of each tower every month, with three towers in total. Since each tower consists of multiple floors, Registered Pharmacist 1 clarified that the nursing stations in each area of the hospital are not inspected monthly. Rather, only one nursing station from each of the three towers, each tower had between two to four floors each with one nursing station on each floor, undergoes inspection by the pharmacist every month. Not all nursing units were inspected monthly.

A review on 08/21/24 of the monthly unit inspections revealed that only one nursing station, was inspected in each tower. This indicates that most of the nursing stations across the hospital did not receive a pharmacist unit inspection monthly, raising concerns about the consistency and thoroughness of these inspections in ensuring proper medication management and patient safety throughout the facility.

During an interview on 8/22/24, at 10:00 AM, Registered Pharmacist 1 provided an overview of the hospital's three towers: the Goodman tower, the Koret tower, and the Friedman tower. Registered Pharmacist 1 explained that the Goodman tower has four floors with four nursing stations, the Koret tower has two floors, and the Friedman tower has three floors. Each of these floors houses one nursing station. Registered Pharmacist 1 confirmed that unit inspections are conducted monthly, with one nursing station from each building being inspected per month. Most of the nursing stations did not have a monthly unit inspection. According to her knowledge, this inspection frequency has remained consistent throughout her one-year tenure at the hospital.