Failure to Ensure Timely Vision Services for Resident with Legal Blindness
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of legal blindness and optic atrophy did not receive timely and appropriate vision care services. The resident had not been seen by an optometrist since a missed appointment, and the missed visit was never rescheduled despite an active request and signed consent for vision care. The resident's care plan included interventions such as arranging consultations with an eye care practitioner and monitoring for acute eye problems, but these interventions were not effectively implemented. Record review and interviews revealed that the process for scheduling vision appointments relied on the resident's request and consent, after which the resident would be placed on a list for quarterly visits by an external provider. However, after the resident missed a scheduled visit due to being in bed, there was no follow-up to ensure the resident remained on the provider's list or to reschedule the appointment. The facility lacked a tracking mechanism to monitor whether visits occurred, were missed, or canceled, and there was no system to identify if a resident was no longer receiving services. The resident reported ongoing vision issues and expressed a desire for a vision appointment, but staff were unaware of the lapse in care and did not inform the resident of any upcoming appointments. Interviews with staff indicated uncertainty about responsibility for tracking missed or discontinued services, and there was no documentation or system in place to ensure continuity of vision care for the resident.