Failure to Coordinate and Prepare Resident for Eye Care Appointments and Procedures
Penalty
Summary
The facility failed to ensure that a resident with severe vision impairment and a diagnosis of glaucoma received treatment and care in accordance with professional standards, the comprehensive care plan, and the resident’s preferences. Specifically, the facility did not adequately prepare the resident for scheduled eye doctor appointments, resulting in missed or delayed care. The resident was not informed of appointment times and relied on the facility to manage his schedule, but there were instances where he was not checked out after appointments, leading to missed follow-ups. The facility also failed to communicate effectively with the eye doctor’s office, as evidenced by multiple unreturned calls and voicemails regarding appointment scheduling. On one occasion, the resident was not kept NPO (nothing by mouth) prior to a scheduled eye surgery, despite clear instructions provided to the facility. The resident was taken to the dining room for breakfast and lunch on the day of the procedure, which led to the surgery being canceled and rescheduled. The eye doctor’s office was not notified by the facility or the resident about the NPO violation; instead, the surgery center informed them after the fact. Additionally, the facility did not ensure that the required medical clearance was obtained prior to another scheduled eye procedure. The eye doctor’s office had to complete the clearance at the last minute to avoid further delay in the resident’s care. Interviews with facility staff revealed a lack of clear responsibility and coordination for managing appointments and pre-operative requirements. The DON, ADM, and activities staff described a collaborative approach but did not designate a specific individual to oversee appointment logistics. There was also a lack of awareness among staff regarding missed appointments, NPO status, and the need for medical clearance, which contributed to the deficiencies in care. Facility policy required advance planning and communication for transportation and appointments, but these procedures were not consistently followed for this resident.