Failure to Arrange Timely Vision Services for Resident with Cataract Complaint
Penalty
Summary
A resident with a history of dementia, anxiety disorder, and glaucoma reported vision problems that affected his ability to participate in recreational activities. The clinical record shows that a physician ordered an optometry consult for the resident's bilateral cataract complaint, but there is no evidence that an optometry appointment was scheduled or completed between the time the order was given and the resident's emergency room visit several months later. During this period, the resident continued to experience vision issues, including an episode of acute vision loss, which ultimately led to an emergency room evaluation and a diagnosis of cataracts in both eyes. Staff documentation and communication indicate that the nursing staff did not arrange the required optometry consult as ordered by the physician. The DON confirmed that she had no additional information regarding the resident's vision concerns and stated that she would have expected nursing staff to set up the appointment when the consult order was issued. The failure to ensure timely access to vision services resulted in a lack of proper treatment to maintain the resident's vision abilities.