Failure to Provide Timely Vision Treatment Following Specialist Recommendation
Penalty
Summary
A deficiency occurred when a resident with a history of hypertension, chronic diastolic heart failure, and type II diabetes was not provided with recommended treatment to maintain vision. The resident had been evaluated by an eye doctor, who diagnosed her with dry eye syndrome in both eyes and recommended artificial tears twice daily. Despite this recommendation, a review of the resident's physician orders did not show any order for artificial tears, and the resident reported waiting several weeks for the prescribed eye drops. Further review of the clinical record and staff interviews revealed that although the physician had signed off on the vision consult, the order for artificial tears was not entered at that time. The Assistant Director of Nursing acknowledged that the order should have been completed when the physician signed off, and the Nursing Home Administrator confirmed this oversight. The lack of timely entry and implementation of the physician's order resulted in the resident not receiving the recommended treatment for her vision needs.