Failure to Provide Vision Services for a Resident
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain the vision ability for a resident with impaired vision. The resident, who was admitted with chronic obstructive pulmonary disease, hypertension, and dementia, was documented as being cognitively intact and using corrective lenses. However, there were no records of optometry consultations or a comprehensive care plan addressing the resident's vision needs. During interviews, the resident expressed the need for a new prescription and confirmed not having seen an eye doctor since admission. A registered nurse acknowledged the lack of an optometry consultation and stated that a request had been made to place the resident on the optometry list.
Plan Of Correction
Plan of Correction: Approved February 21, 2025 1. Resident #28 A. An eye examination is scheduled for (MONTH) 14, 2025. 2. Other residents with visual deficits have the potential to be affected by this alleged deficient practice. A full house audit of all residents was completed on 2/18/2025 by the Intake Manager to identify residents with visual impairment. Each current resident identified as having visual impairment was offered an eye examination on 2/21/2025. The resident representative was contacted for all residents identified with visual impairment, who cannot make their own decisions on 2/21/2025. There were 15 additional residents identified with visual impairment whose last eye exam was over 1 year. 5 of the 15 residents and the other 10 declined. 3. The policy Vision and Hearing was created by the Director of Nursing on 2/18/2025. The Vision and Hearing Policy will include required consult documentation and comprehensive care plan development for Vision and hearing. B. All Nursing staff and the administrator will be educated on the Vision and Hearing Policy. Staff will complete a written post test to ensure comprehension of the policy. Education will be completed prior to 3/4/2025. 4. All current resident's Minimum Data Set Assessments will be reviewed to identify vision and or hearing needs. Residents identified as having vision or hearing needs will have consultations scheduled and upon admission for new residents then as needed. 5. A monthly audit will be completed for all residents to ensure vision appointments have been offered per policy. All Audit results will be reported to the monthly Quality Committee until three consecutive months of compliance is achieved then at the direction of the committee. 6. Director of Nursing / Designee