Failure to Assess and Monitor Resident's Eye Condition
Penalty
Summary
A resident with diagnoses including schizophrenia and neuromuscular dysfunction of the bladder was observed to have a solid red discoloration on the bottom portion of the sclera in her right eye. The resident reported that the redness had been present for some time, though she was initially unaware of it until nursing staff pointed it out. Observations on two separate occasions confirmed the persistent redness. Review of the resident's medical record revealed no documentation of assessment or monitoring of the right eye discoloration. During an interview, the DON confirmed there was no further information available regarding the resident's red eye. The deficiency was identified due to the facility's failure to assess and monitor the resident's eye condition as required, despite clear evidence of an ongoing issue.