Failure to Provide Timely Optometry Services
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain the vision ability of a resident, identified as Resident #70, who was reviewed for communication. Resident #70, who was admitted with chronic obstructive pulmonary disease, hypertension, and seizures, was documented as having impaired vision and using corrective lenses. The facility's policy required timely medical care, yet the resident's medical record showed no optometry consults or a comprehensive care plan for vision after a scheduled follow-up in March 2023. Interviews revealed that the resident expressed a desire to see an eye doctor, and a registered nurse acknowledged the need for optometry visits every 6-12 months. However, there was a lack of documented follow-up or scheduling for optometry services. The medical records staff indicated they rely on nurse managers to email them for scheduling appointments, but no such communication was documented for Resident #70, leading to a deficiency in providing necessary vision care.
Plan Of Correction
Plan of Correction: Approved January 17, 2025 1. Immediate corrective action: Resident #70 was seen by optometry on 3/25/2024 with recommendations to follow up in 1 year. Medical records clerk was re-educated on scanning consults into resident’s chart timely on 1/13/2025. 2. Plan to prevent reoccurrence: Medical records completed a full house review of facility resident’s optometry consults from the previous 12 months to identify any additional missed scanned consults. This audit was completed on 1/17/2025. Results of the audit will be provided to medical provider for review. 3. The facility systemic changes: Education was given to medical records on 1/13/2025 by the Director of Nursing to ensure they are following the consultation policy. Medical records will document and monitor vision consults utilizing a consultation tracker form to ensure completed consults are scanned into resident chart. 4. Medical records coordinator will conduct a review of residents’ vision consults weekly x 4 weeks then monthly x 3 months. Results will be submitted to the Director of Nursing for final review. The results of the reviews will be brought to QAPI for review and determination of frequency reviews and any additional recommendations. Responsible Party: Director of Nursing