Failure to Notify Physician and DON of Resident's Eye Condition Change
Penalty
Summary
Staff failed to notify the physician and Director of Nursing (DON) of a change in a resident's eye condition. The resident, who had diagnoses of glaucoma, dementia, and cataract, was observed with a red, swollen left eye with mucus drainage. Despite these visible symptoms and the resident rubbing the affected eye, staff did not provide assistance or perform eye care during the initial observation. Later, the resident's left eye was found closed shut with dried fluid and mucous around the eyelid. There was no documentation in the medical record regarding the eye redness, fluid drainage, or swelling, nor was there any record of physician notification. During interviews, the RN acknowledged observing the resident's eye closed with redness and fluid/mucous, and stated she wiped the eye with a warm washcloth but did not document the condition, notify the DON, or contact the physician. The DON confirmed that her expectation was for RNs to report any resident changes to her and the physician, and stated that staff did not report the eye changes for further assessment and provider notification. The Administrator also stated that the RN should have reported the change in the resident's eye condition to the DON and that staff are expected to communicate any change in residents.