Failure to Provide Timely Ophthalmology Services for Resident with Ongoing Eye Symptoms
Penalty
Summary
The facility failed to ensure that a resident with a history of type 2 diabetes and essential hypertension received appropriate ophthalmology services as required by physician orders, resident preferences, and facility policy. The resident, who was moderately cognitively impaired and required maximum assistance with activities of daily living, experienced untreated bilateral itchy and discolored eyes since admission. Multiple staff members, including a CNA and LVN, observed the resident rubbing her eyes and noted discoloration but did not report these symptoms to nursing or medical staff. A family member also reported the resident's ongoing eye issues to a charge nurse, but there was no evidence that this concern was communicated to a physician or resulted in an ophthalmology referral. Record reviews confirmed that there were no active orders for ophthalmology services for the resident, and no documentation indicated that the resident had been seen by an eye doctor since admission. The Director of Social Services and DON both acknowledged that the resident had not been scheduled for or received eye care in accordance with facility policy, which required eye doctor visits every 3-6 months and as needed. The ophthalmologist confirmed that he had not been notified of the resident's symptoms and only conducted annual visits. The administrator stated that residents are seen by the ophthalmologist based on need, but also indicated there was no formal policy for eye or vision care in place.