Failure to Schedule Cataract Surgery Referral for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely follow-up for vision care as recommended by a specialist. The resident, who had multiple diagnoses including acute kidney injury, type 2 diabetes mellitus, major depressive disorder, anxiety, insomnia, muscle weakness, and cervicalgia, was seen by an ophthalmologist who recommended a cataract evaluation and possible surgery. Documentation in the medical record showed an order for referral to an ophthalmologist for cataract surgery, but there was no evidence that the referral was sent or an appointment scheduled. Interviews with the resident and the unit manager confirmed that the surgery had not been scheduled, despite the facility being aware of the need for follow-up since February.