The nurse, who served as both charge nurse and medication administration nurse for the day shift on November 24, admitted to federal inspectors that although the resident's ordered eye medication was present in her medication cart, she had not administered it as scheduled.
The missed 6 AM dose was never mentioned during shift report, the nurse told inspectors. She also acknowledged that she did not assess the resident's pain level at any point during her shift.
The facility's Director of Nursing told inspectors during a concurrent interview that the medication omission should have been documented, explained, and endorsed by the licensed nurses. The nursing director said the facility should have initiated a comprehensive care plan for the resident's left eye blindness to ensure continuity of care between shifts.
Without proper care planning, the director acknowledged, the resident was placed at risk for unmet needs and worsening health condition due to lack of interventions.
Federal inspectors found the facility violated care planning requirements. According to the facility's own policy dated August 25, 2021, the interdisciplinary team is responsible for developing an individualized comprehensive care plan for each resident within seven days of completing the comprehensive assessment.
The facility's nursing documentation policy, dated June 27, 2022, requires nursing documentation to include information about the patient's status, nursing assessment, interventions and expected outcomes, evaluation of patient's outcomes, and responses to nursing care.
None of this happened for the resident with left eye blindness.
The inspection was conducted in response to a complaint. Federal inspectors determined the violations caused minimal harm or potential for actual harm and affected few residents.
The nursing director's admission that the resident was at risk for worsening health condition highlights how medication errors compound when facilities fail to implement basic care planning protocols for vulnerable residents with existing disabilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fountain View Subacute and Nursing Center from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
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