Failure to Ensure Follow-Up Vision Care for Resident with Cortical Blindness
Penalty
Summary
The facility failed to ensure that a resident with highly impaired vision received the necessary follow-up care as directed by their care plan and the facility's sensory impairment policy. The resident, who had a history of stroke resulting in cortical blindness, was identified through assessments and care planning as being at risk for safety issues, distress, and isolation due to their vision impairment. Staff were instructed to arrange consultations with eye care practitioners as required. Despite documentation that the resident attended an eye exam and was scheduled for a six-month follow-up, there was no evidence in the resident's records that the follow-up appointment occurred or that the missed appointment was addressed. The eye specialist clinic confirmed that the resident did not return for the scheduled follow-up, and staff interviews revealed an inability to locate any documentation regarding the missed appointment. This lack of follow-through resulted in the resident not receiving the ongoing vision care specified in their care plan.