Failure to Provide Vision Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities, as required by regulation 483.25(a). The resident, who was admitted with a diagnosis of [REDACTED], was cognitively intact and able to communicate effectively. Despite expressing difficulty with vision and the ineffectiveness of their old glasses, the resident had not been provided with an eye exam, new glasses, or a follow-up ophthalmology appointment since their admission. The last ophthalmology consult was dated July 2020, prior to the resident's admission, and recommended a follow-up in three months, which was not arranged by the facility. The resident's Comprehensive Care Plan, dated December 2024, did not include any plan for vision care or glasses. Interviews with the Director of Nursing and a Registered Nurse revealed that the resident had not been seen by an ophthalmologist since admission, and it was the unit manager's responsibility to coordinate such follow-up visits. The Registered Nurse was unaware that the resident wore glasses and acknowledged the omission in the care plan, indicating a lack of awareness and coordination in addressing the resident's vision needs.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 Corrective Action for those identified: Resident #19 has an ophthalmology appointment scheduled for 3/14/25 at 1500. The care plan for Resident #19 was updated to include vision concerns and use of eye glasses on 2/14/25. Identification of other residents and corrective action: All residents are at risk for the deficient practice. An audit of all residents for indication for follow up vision assessments and/or use of eyeglasses will be completed to ensure care planning (inclusive of scheduling of necessary follow up appointment) is completed appropriately. Measures and Systemic Changes: A new policy “Care of Visually Impaired Residents” was initiated on 3/11/2025. Education of pertinent staff related to the new policy will be completed by 3/31/25. Monitoring: An audit of all new admissions will be conducted to ensure vision treatment and assistive devices are appropriately addressed. This will occur weekly x 4 weeks and then monthly x 3 months. Results of the audits will be reported to and reviewed by the Quality Assurance Performance Improvement (QAPI) Committee monthly. Modification, discontinuation or continuation of audits will be based on QAPI Committee recommendations. Responsible person/title and date of correction: Annmarie Mogensen, Director of Nursing, by 3/31/25.