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F0685
D

Failure to Provide Timely Vision Services

Tacoma, Washington Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide prompt vision services to a resident who required new corrective lenses. The resident, who had a history of diabetes and depression, was readmitted to the facility and had a neuro-ophthalmology consultation that resulted in a new prescription for glasses. Despite the prescription being available in early February, the resident reported in May that they had not received the new glasses, and staff were aware of this issue. The resident's electronic health record indicated adequate vision with corrective lenses, but the recommended new glasses were not obtained in a timely manner. Interviews with facility staff revealed a breakdown in communication and follow-up regarding the prescription. The Unit Manager/RN acknowledged that the prescription should have been addressed sooner, and the Health Information Clerk stated they never received the prescription from nursing, which prevented them from processing it with the in-house optometrist. The Director of Nursing Services was also unaware that the prescription had not been filled and noted that proper communication between nursing and health information/medical records was lacking. This failure resulted in the resident not receiving necessary vision services as recommended by their provider.

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