Failure to Ensure Timely Specialty Eye Care Appointments
Penalty
Summary
The facility failed to ensure that a resident with a history of corneal transplant surgery and multiple eye conditions received recommended follow-up care with a specialty eye doctor. Despite documented recommendations from both the resident and medical providers for ongoing ophthalmology appointments, the facility did not consistently schedule or facilitate these appointments. The resident reported repeated requests for assistance in scheduling and attending eye specialist visits, but either received no follow-up or was told that staff were unavailable to escort them, leading the resident to eventually stop asking for help. Medical records and interviews confirmed that the resident had missed several scheduled and recommended eye appointments, with the last documented visit occurring in the previous year. The resident's vision continued to deteriorate, and there were missed opportunities for follow-up surgery and medication management as noted by the eye specialist's office. Facility staff, including the Unit Manager and Clinical Coordinator, were either unaware of the resident's ongoing need for specialty eye care or unable to provide documentation of efforts to ensure these services were provided. The facility's own policy required nursing staff to review and act on ancillary service recommendations, document services provided, and communicate with providers and families. However, interviews with staff revealed a lack of clarity regarding responsibility for scheduling and tracking ancillary appointments, and no evidence was found that the resident's need for continued specialty eye care was addressed in accordance with policy or medical recommendations.