Failure to Provide Functional Glasses for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with impaired vision had access to a functional pair of glasses as required by her care plan and physician orders. The resident, who had diagnoses including dementia, hypertension, and a history of falls, was dependent on staff for all activities of daily living and required full assistance, including the use of a wheelchair and mechanical lift. Her care plan and medical orders specified that staff were to assist with her glasses, ensuring they were worn during awake hours and stored in the medication room when not in use. Despite these directives, the resident's glasses remained broken for an extended period, and she was observed without them on multiple occasions. Staff interviews and record reviews revealed that the facility was aware of the broken glasses since early July, but the resident's representative was not notified, and no action was taken to repair or replace the glasses. Administrative staff stated they were unaware of the issue and would have acted had they known. The facility's policy required staff to report problems with glasses to a licensed nurse, but this did not occur, resulting in the resident not having access to her necessary visual aid for an extended period.