Failure to Arrange Timely Ophthalmology Referral and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received timely referral, appointment, and follow-up for ophthalmology services as ordered by the physician. The resident, who had a history of diabetes, heart failure, and chronic kidney disease, was documented as needing an ophthalmology consultation for diabetic eye examination and cataract management. Despite physician orders and an eye doctor consultation recommending follow-up for cataracts and referral for occult macular dystrophy, the necessary arrangements for these services were not made. Record reviews showed that the resident had been waiting for new glasses for a year and was using inadequate over-the-counter glasses, which did not sufficiently address her vision needs. Interviews with staff revealed that the process for arranging such appointments required communication between licensed nurses, case managers, and the social service director (SSD). However, the SSD was unaware of the eye doctor consultation and its recommendations until the time of the survey, indicating a breakdown in communication and follow-through on the referral process. Facility policy required that social services or their designee assist with appointments, referrals, and transportation for ancillary services, and that orders for such services be relayed promptly. Despite these policies, the resident's referral and follow-up for vision care were not completed, and staff acknowledged that failure to arrange these services could result in worsening vision for the resident.