Failure to Reschedule Ophthalmology Appointment for Resident with Vision Impairment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities by not rescheduling an ophthalmology appointment after a missed visit. The resident, an older adult with diagnoses including type 2 diabetes mellitus, dementia, and cognitive deficits following cerebrovascular disease, had a standing order for ophthalmology evaluation and treatment. Documentation showed that the resident had previously been referred to an ophthalmologist for retinal and cataract evaluation due to complaints of blurred and watery vision, with diagnoses of cataracts and proliferative diabetic retinopathy with macular edema. The initial ophthalmology appointment was missed because the family member who was supposed to accompany the resident did not attend, and the facility was informed that the appointment would need to be rescheduled. Despite this, there was no evidence in the medical record that the appointment was rescheduled or that further action was taken to ensure the resident received the necessary evaluation. Interviews with facility staff revealed a lack of awareness regarding the missed appointment and the need for rescheduling. The resident continued to experience vision difficulties, impacting her ability to participate in activities, and was unsure about her vision care history. The absence of follow-up and coordination resulted in a delay in the resident receiving appropriate ophthalmology care as ordered.