Failure to Provide Timely Eye Care for Resident
Penalty
Summary
The facility failed to provide proper treatment and assistive devices to maintain vision for a resident, identified as Resident #55, who reported changes in eyesight. Despite the resident's cognitive intactness and ability to see fine detail, they experienced changes in vision starting in 2024, which they reported to the facility staff. However, the facility did not ensure timely medical attention or follow-up with the resident's eye doctor as recommended by the medical provider. A progress note indicated that an appointment was scheduled for March 2025, but the resident missed this appointment due to a lack of transportation arrangements. The deficiency was further compounded by the facility's failure to act on the resident's complaints in a timely manner. The Certified Nursing Assistant Unit Clerk, responsible for scheduling appointments and arranging transportation, was unaware of the resident's need for an earlier appointment and did not arrange transportation for the scheduled appointment. The Director of Nursing acknowledged a 25-day gap between the resident's complaint and their visit with the facility medical provider, indicating a lapse in timely care. The facility's policy required that eye examinations and services be obtained as ordered by the attending physician, but this was not adhered to, resulting in the resident missing necessary eye care.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective action for the affected residents: Resident #55 was scheduled and attended a follow up eye appointment on 4/16/25. No changes recommended. Follow up schedule for 4 months. Identification of potentially affected residents: Residents that have reported a change in vision or require follow up eye appointments are at risk for this deficiency. All residents that require a follow up eye appointment will be identified and appointments/transportation will be arranged. Measures to prevent reoccurrence: Education will be provided to the unit clerk, unit managers, social workers, and medical records. This will include review of the facility policy, Clinic/Consult Appointment. Emphasis will be placed on the importance of scheduling/rescheduling appointments in a timely manner. Documentation and notification of the DON will be expected in the event that an appointment cannot be attended. Continued compliance: The facility staff will complete auditing for compliance. Auditing will be completed of all appointments weekly for a month then 6 per month on all residents with out of the facility appointments to ensure attendance and that follow up is completed appropriately. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. DON is responsible for compliance.