Failure to Complete Significant Change Assessment for Vision Decline
Penalty
Summary
The facility failed to ensure that a resident who experienced a significant change in condition, specifically a decline in vision, was comprehensively assessed within 14 days as required. The resident, an older adult with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Cognitive Communication Deficit, was noted in a physician's progress note to have cataracts and was recommended for follow-up with an ophthalmologist for possible surgery. Despite this, the resident's Quarterly MDS assessment did not reflect any vision impairment or use of corrective lenses, and her care plan did not mention vision issues or the need for eye care or surgery. Interviews and record reviews revealed that the resident expressed difficulty seeing, required eyeglasses, and reported urgent need for an eye doctor due to declining vision. The social worker made several attempts to arrange an eye exam and surgery, but was unsuccessful due to transportation challenges related to the resident's size and a fall during a previous transport attempt. These efforts were not documented in writing. The MDS nurse stated that vision issues were not included in the MDS because there was no formal diagnosis from an eye doctor, despite a nurse practitioner's note mentioning cataracts. Other staff, including the ADON and Administrator, were either unaware of the vision decline or unsure of the requirements for documenting vision impairment in the MDS. The facility did not have a specific policy for MDS assessments and relied on the RAI Manual. The DON acknowledged that vision impairment should be noted on the MDS and that failure to do so could result in the resident not receiving necessary eye care. The RAI Manual outlines the importance of assessing and documenting vision impairment and the use of corrective lenses, but these steps were not followed for this resident, resulting in the deficiency.