Failure to Facilitate Access to Vision Services for Resident with Visual Impairment
Penalty
Summary
A deficiency was identified when the facility failed to provide or facilitate access to visual services for a resident with impaired visual function. The resident had a history of major depressive disorder and cerebrovascular accident, resulting in a left-sided visual deficit. Despite having a physician's order allowing for specialist visits, including an eye doctor, there was no evidence in the electronic health record (EHR) that visual services were offered or facilitated, nor was there documentation that the resident declined such services. The resident reported requesting an eye exam and stated she could not read without glasses, yet had never received eyeglasses during her stay at the facility. Interviews with facility staff revealed that when a resident requested vision services, the process involved documenting the request in the EHR or informing the Social Services Designee (SSD). However, the SSD could not locate any documentation of a declined consent or progress note regarding visual services for this resident. The facility's policy required the provision of necessary care and services, including assistance with making vision appointments, but this was not followed in the resident's case. The lack of action placed the resident at risk for further deterioration of vision.