Failure to Facilitate Timely Cataract Surgery Referral and Follow-Up
Penalty
Summary
The facility failed to ensure timely referral and follow-up for cataract surgery for a resident diagnosed with cataracts who expressed difficulty with vision. The resident, who had moderate cognitive impairment and multiple medical conditions including high blood pressure and diabetes, was observed without glasses and reported poor vision. The Minimum Data Set (MDS) section for vision status was left blank, and the resident's care plan did not address vision problems beyond noting the presence of a guardian and long-term care status. Documentation showed that the resident was seen by in-house optometry services, which identified cataracts in both eyes and recommended a referral for cataract surgery. The optometrist attempted to contact the resident's guardian but was unsuccessful, and no further referral was made. The medical record lacked evidence that the recommendation for cataract surgery was discussed with the resident's guardian or that any follow-up attempts were made after the initial failed contact. Both the previous and current guardians confirmed they were not informed about the need for cataract surgery. Interviews with facility staff, including the social worker, nurse manager, and DON, revealed a lack of communication and documentation regarding the need for cataract surgery and the process for follow-up. Staff acknowledged that attempts to contact guardians for medical care input should be documented, but this was not done. The facility's policy required staff to coordinate and document necessary appointments and follow-ups, but this was not followed in the resident's case.