Failure to Coordinate and Follow Up on Vision Services Referral
Penalty
Summary
The facility failed to ensure proper follow-up and coordination of vision services for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia and heart failure. The resident was evaluated by an optometrist, who recommended a referral for cataract surgery due to blurry vision in both eyes. Despite this recommendation, there was no documentation in the electronic medical record indicating that a referral to an ophthalmologist was made or that further tests for cataract surgery were scheduled. Interviews with facility staff revealed that the social service director received the referral in February and passed it to the transportation staff member but did not follow up on the process. The transportation coordinator reported not receiving the referral and acknowledged that the scheduling was missed. The facility's policy required social services to coordinate and assist with vision services, but this process was not completed, resulting in the resident not receiving the recommended follow-up care.