Failure to Coordinate Follow-Up Vision Appointment
Penalty
Summary
A deficiency occurred when the facility failed to coordinate a follow-up vision appointment with a retina specialist for a resident diagnosed with end stage macular degeneration. The resident, who had intact cognition and required moderate assistance with activities of daily living, was seen by an eye doctor at the facility who recommended a follow-up with a retina specialist within one to two weeks. A physician order was entered for this referral, and the order was given to the unit manager to schedule the appointment. However, there was no evidence that the appointment was ever scheduled or completed, and the unit manager responsible for this task was no longer employed at the facility. The resident reported having requested the appointment multiple times and not being informed of any scheduled visit. Review of facility policy indicated that social services should collaborate with nursing staff to arrange such referrals and document them in the medical record, but no documentation of the referral or appointment was found. Interviews with facility staff confirmed the lack of follow-through on the physician's order, resulting in the resident not receiving the recommended specialist care.