Failure to Revise Care Plan and Follow Up on Vision Needs
Penalty
Summary
The facility failed to review and revise a resident's care plan with input from the resident to address vision needs, specifically for a resident with a history of cataracts and aphasia. The resident's quarterly MDS indicated moderately impaired cognition, adequate vision, and no use of corrective lenses, despite a diagnosis of bilateral age-related cataracts. The Care Area Assessment (CAA) triggered by the cataracts noted the need to maintain current visual function and referenced a consultation for cataract extraction, which the resident elected to pursue. However, the care plan, last revised several months later, did not document the use of multiple pairs of non-prescription glasses or follow-up on the cataract extraction referral and new eyeglasses order. Review of the resident's electronic health record (EHR) revealed a lack of documentation that the referral to a cataract extraction specialist was followed up, and there was no evidence that the order for a consult to optometry for new eyeglasses was addressed. Observations showed the resident using eyeglasses with a missing left temple, and the resident reported ongoing cataract issues, difficulty seeing without glasses, and a need for a new pair. Interviews with the optometrist confirmed that a referral for cataract extraction had been placed and that the facility was responsible for scheduling, but there was no record of the resident requesting eyeglasses or the facility communicating this need. Further, the care conference documentation did not indicate whether the resident or their representative's input was considered in the care planning process. The DON stated that staff were expected to follow up on appointment referrals and that resident preferences and interventions were discussed during care conferences, but also acknowledged that documentation of the use of over-the-counter non-prescription eyeglasses was lacking. Facility policy required person-centered care planning with resident participation and timely updates as needs changed, but these requirements were not met in this case.