Failure to Provide Recommended Vision Services
Penalty
Summary
The facility failed to ensure that vision services were provided as recommended by a vision specialist for a resident with multiple diagnoses, including Alzheimer's disease, dementia, and subdural hemorrhage. Medical record review showed that the resident was cognitively impaired and dependent on staff for mobility and activities of daily living. An eye exam documented a recommendation for cataract surgery and an ophthalmology consult, with a follow-up visit to occur in five to six months. However, there was no documentation in the medical record of any follow-up regarding the cataract surgery or subsequent eye provider visits. The resident's care plan did not include information about vision impairment or the recommended follow-up for the cataract procedure. Interviews with the resident's family and facility staff confirmed that no evidence existed of staff arranging or following up on the recommended ophthalmology consult or follow-up appointments. Facility policy required the social services department to make necessary referrals for eye care services, but this was not documented as completed.