Failure to Ensure Vision Services for Resident with Visual Impairment
Penalty
Summary
A deficiency was identified when a resident with a known diagnosis of macular degeneration and documented visual impairment was not evaluated for treatment or services to maintain her vision. The resident expressed concerns about her ability to navigate her environment due to her eyesight deficits, and it was noted in her care plan that an ophthalmologist or optometrist consult should be arranged as indicated. Despite these documented needs and the resident's own reports of difficulty seeing and inability to read, there was no evidence that a vision evaluation or referral had been made during her stay. Multiple staff interviews revealed that while the resident's poor vision was known, and accommodations were made to help her locate personal items, no one had initiated a referral for a vision assessment. The social worker stated that residents are typically signed up for in-house vision services when notified by nursing or upon resident request, but the resident was not on the list to be seen. Nursing staff acknowledged the resident's complaints about her glasses not working but did not pursue further evaluation, and the nurse practitioner indicated she would have expected a vision evaluation if the resident was having difficulty seeing. The resident herself reported that she could not remember the last time she was seen by an eye doctor and expressed interest in obtaining new glasses to improve her vision. Despite her ongoing vision difficulties and the impact on her ability to engage in preferred activities such as reading, no recent vision services or evaluations were provided. The lack of action to address her visual impairment, despite clear indications and care plan interventions, led to the identified deficiency.