Failure to Coordinate Timely Optometry Services for Resident with Broken Glasses
Penalty
Summary
The facility failed to coordinate optometry services for a resident who requested them, resulting in the resident wearing eyeglasses with a missing right lens for an extended period. The resident, who was cognitively intact and had diagnoses including major depressive disorder and diabetes cellulitis, was readmitted to the facility with broken glasses. Documentation showed that the broken glasses were noted upon readmission, and a physician's order for an ophthalmology consult and treatment was present. Despite this, the resident reported waiting months to see the optometrist, and the facility did not arrange for the resident to be seen during the optometrist's scheduled visit. Interviews with facility staff revealed that the resident had communicated the need for optometry services to a CNA, and the Social Services Director confirmed the optometrist's regular schedule but acknowledged the resident was not seen. The Director of Nursing stated that an authorization for ancillary care should have been requested sooner after the broken glasses were identified. The facility's policy required social services to coordinate referrals for medical services based on physician orders and to document these referrals, but this process was not followed in this case.