Failure to Obtain Vision Consultation for Resident
Penalty
Summary
The facility failed to ensure that a consultation with an optometrist or ophthalmologist was obtained for a resident, identified as Resident R201, who was part of a group of 35 residents reviewed. The deficiency was identified through observations, clinical record reviews, and interviews with the resident's family and staff. The resident's family member, who visits daily, reported having requested an eye examination for the resident multiple times over several months, specifically in November and December 2024, and January 2025. Despite these requests, there was no documentation indicating that the consultation had been discussed with the physician or that any action had been taken to arrange for the resident to be evaluated by an eye specialist. Resident R201 was admitted to the facility in September 2024 and was noted to be severely cognitively impaired with a diagnosis of dementia. Observations revealed that the resident was unable to follow objects with her eyes and did not have corrective eyewear, suggesting a need for corrective lenses. Interviews with the nursing staff confirmed the family's repeated requests for an eye specialist consultation, yet no vision consults were available for review. This lack of action and documentation led to the determination that the facility did not meet the requirement to assist the resident in maintaining vision abilities.
Plan Of Correction
1. R201 has an appointment scheduled with the optometrist on 2/19/25. 2. An audit was completed for residents to determine if they have had any vision concerns and/or wish to be seen by the optometrist. 3. Education was completed with licensed nurses regarding communicating with the optometrist for residents who report vision concerns. 4. The DON/Designee will audit the nursing 24-hour report, weekly x 4 weeks then monthly x 2 months to assure that any resident noted with vision concerns are communicated to the optometrist. Findings of the audits will be reported to monthly QA x3.