Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities by not assisting in making necessary appointments for vision services. The resident, who had severe cognitive impairment and multiple diagnoses including vascular dementia and heart failure, was identified as being at risk for impaired visual function. The care plan included interventions such as arranging consultations with an eye care practitioner and reminding the resident to wear glasses. Despite these interventions, the resident did not have corrective lenses and did not receive timely assistance in obtaining an eye exam or having her glasses repaired or replaced. The resident's family began requesting assistance with the resident's glasses in early March, reporting that the glasses were loose and needed adjustment. Over the following months, the family repeatedly followed up with various facility staff regarding the status of the glasses and the need for an eye exam. The situation was complicated by staff turnover, including the departure of the staff member initially handling the request and the absence of a social worker for a period of time. Communication between the family and facility staff documented ongoing concerns about the resident's missing or broken glasses and the lack of an optometrist appointment. Facility staff acknowledged that the optometry provider required a minimum number of residents to schedule a visit, which further delayed the resident's access to vision services. The administrator and social worker confirmed that the resident's vision needs were not addressed due to staff changes and procedural delays. The resident remained without corrective lenses or an eye exam for several months, despite ongoing requests and documented needs.