Failure to Arrange Ophthalmology Appointment for Resident with Severe Vision Impairment
Penalty
Summary
The facility failed to arrange a specialty physician appointment for a resident with a history of blindness in one eye, low vision in the other, and a diagnosis of cortical age-related cataract in the right eye. Despite multiple physician orders and care plan interventions indicating the need for ophthalmology evaluation and treatment for cataracts and worsening vision, the resident did not receive an appointment with an eye doctor for an extended period. Documentation showed repeated referrals and urgent requests for ophthalmology consultation, but the resident reported never having seen an eye doctor since admission. Staff interviews confirmed the resident's ongoing vision impairment and the lack of successful appointment scheduling due to insurance issues and difficulty finding a provider who accepted the resident's insurance and treated cataracts. Observations revealed the resident ambulating with a slow gait, using hands to navigate due to severely impaired vision. The resident expressed that his vision had worsened during his stay and described pain in his right eye. The facility's transportation staff kept only handwritten notes to track appointment attempts, and there was no documented evidence of consistent follow-up or outreach to ophthalmologists. The facility's policy required physician orders to be followed as written, but there was no proof that the necessary steps were taken to ensure the resident received timely ophthalmology care.