Failure to Provide Vision Services to Residents with Visual Impairment
Penalty
Summary
Facility staff failed to ensure that two residents received necessary vision services. One resident, with a history of primary open-angle glaucoma and diabetes, was coded as having moderate visual impairment and required corrective lenses. Despite care plan interventions to arrange consultations with an eye care practitioner and physician orders for an eye exam and eyeglasses, there was no documentation that these services were provided. Staff interviews revealed that the resident had requested assistance obtaining glasses, but no appointment was made, and the resident was not included on the list for the vision van visit. The resident reported being blind and only able to see people as gray shadows, and staff acknowledged awareness of the need but did not follow through with scheduling the required services. Another resident, with diagnoses including dementia, schizophrenia, and severe cognitive impairment, also did not receive routine vision screening since admission. The resident expressed difficulty seeing and an inability to recall the last eye examination. Review of the clinical record confirmed that the resident had not been seen by an optometrist since admission. Administration staff confirmed that routine vision screenings should occur annually and that the resident had not been scheduled for such services. Interviews with staff and review of facility documentation indicated a lack of communication and follow-through in identifying and scheduling residents in need of vision services. The process relied on unit managers to notify the person responsible for arranging appointments, but this did not occur for the affected residents. As a result, both residents with documented visual impairments did not receive timely or appropriate vision care as required.