Failure to Arrange and Document Ophthalmology Consult for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain their vision. The resident was observed squinting and having difficulty watching TV, and reported having requested an eye appointment that was not arranged by the facility. Review of the resident's Minimum Data Set (MDS) showed a decline in vision from adequate to moderately impaired over time. Medical records indicated that ophthalmology consults were ordered on two separate occasions, but there was no evidence that these consults were ever completed. The social services director confirmed there was no documentation explaining why the consult ordered in January was not done. Facility policy required social services to coordinate and document referrals, but this was not followed in this case.