Failure to Follow Up on Vision Consults and Provide Hearing Assistive Devices
Penalty
Summary
The facility failed to follow up on vision-related consults and provide necessary assistive devices for hearing for two residents. One resident with a history of cataracts, hemiplegia, and aphasia had multiple documented orders and recommendations for a cataract extraction consultation and new eyeglasses. Despite repeated documentation from optometry and provider notes indicating the need for a cataract extraction consult and new eyeglasses, there was no evidence in the electronic health record that these referrals were followed up on or scheduled. The resident continued to experience vision difficulties and used broken eyeglasses, with no documentation of timely action taken to address these needs. Interviews with facility staff, including the optometrist, health information management (HIM), LPN, and DON, confirmed that the process for handling referrals and consults was not consistently followed. Orders for vision care were not properly communicated or acted upon, and there was a lack of documentation regarding the status of referrals. The HIM and DON acknowledged that consults should have been forwarded and scheduled, and that there was an expectation for documentation of over-the-counter eyeglasses provided to the resident, which was not present in the record. For another resident with moderate hearing loss, the facility failed to ensure consistent use of an assistive hearing device (pocket talker) as directed in the care plan. Observations showed that staff did not offer or utilize the device during care interactions, and some staff were unaware of its intended use, mistaking it for a music device. Interviews with nursing staff and the DON confirmed that staff were expected to use assistive hearing devices for residents with communication deficits, but there was uncertainty about training and proper implementation. Requested policies related to communication devices and vision treatment were not provided.