Failure to Follow Up on Ophthalmology Referral for Resident with Glaucoma
Penalty
Summary
A deficiency occurred when the facility failed to follow up on an ophthalmology referral for one of two sampled residents with a diagnosis of glaucoma, muscle weakness, and anxiety. The resident was admitted with impaired vision, required medications for glaucoma, and had a care plan addressing impaired visual function. Despite a referral to an eye specialist for glaucoma and cataract removal, there was no evidence that the resident was seen by the specialist. The resident expressed difficulty seeing, a desire to read, and reported being blind in one eye and needing glasses for the other. During observation, the resident was found without eyeglasses and stated he needed assistance. Interviews with social services and the DON confirmed that the referral was not followed up, and the resident was not sent to the eye specialist as ordered. The facility's policy required social services to coordinate and arrange such referrals, including transportation and collaboration with nursing staff. The failure to ensure the resident's access to necessary vision services was acknowledged by staff and was not in accordance with facility policy.