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F0685
D

Failure to Provide Necessary Vision Services Due to Lack of Coordination

Saugus, Massachusetts Survey Completed on 06-16-2025

Penalty

Fine: $93,020
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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 ensure that a resident received necessary vision services. The resident, who had a history of hyperglycemia and repeated falls, was admitted with diagnoses that included cataracts and macular degeneration in both eyes. Despite multiple documented requests by the resident and nurse practitioner for a referral and follow-up for cataract surgery, the resident did not receive the required surgical intervention. An appointment for an eye procedure was canceled due to insurance issues, and there was no evidence that the facility took further steps to resolve the insurance problem or reschedule the appointment. The resident continued to express concerns about his/her vision and the lack of assistance in obtaining surgery for an extended period. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for coordinating vision care services. The resident's nurse was unaware of any vision issues or the process for arranging eye doctor appointments. The social worker stated she was not involved in scheduling such services, while the medical records coordinator indicated her role was limited to enrolling residents and forwarding provider notes to the DON. The DON acknowledged being unaware of the insurance issue and stated that, had he known, he would have intervened. This lack of coordination and follow-through resulted in the resident not receiving timely and necessary vision care.

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