Failure to Implement Eye Doctor's Order for Vision Treatment
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of dry eye syndrome and moderate cognitive impairment did not receive prescribed treatment to maintain visual function. The resident's care plan identified impaired visual function related to dry eyes and included instructions to review medications for side effects affecting vision. An eye doctor consultation documented a new order for Theratears, to be administered three times daily to the resident's right eye due to entropion. However, this order was not added to the resident's active medication list, and there was no documentation explaining why the order was not carried out. Interviews with facility staff confirmed that new orders from specialists are typically verified and implemented, with the DON notified of changes. Despite this process, the DON acknowledged that the eye doctor's order for Theratears was not executed and that there was no record of the rationale for this omission. The facility's policy required staff to adjust interventions based on physician orders and changes in the resident's condition, but this protocol was not followed in this instance.