Failure to Assess and Document Change in Condition Following Eye Redness
Penalty
Summary
The facility failed to provide necessary care and services to maintain a resident's highest practicable physical well-being after a change in condition was reported. On 08/29/2025, a family representative notified nursing staff of redness in the resident's right eye. There was no documented nursing assessment, change-in-condition evaluation, or physician notification at that time. The medical record did not show that staff identified the redness prior to the family report, nor was there any documentation of a registered nurse assessment or a physician evaluation when ciprofloxacin ophthalmic drops were ordered and initiated. The first medical provider assessment occurred six days after the initial report, at which time the resident was diagnosed with a subconjunctival hemorrhage. The resident involved had severe cognitive impairment and multiple medical diagnoses, including dementia, anemia, and systemic lupus erythematosus. Interviews with facility staff confirmed that no assessment or documentation was completed at the time of the reported change in condition. The order for antibiotic eye drops was placed without a documented clinical rationale or provider assessment, and staff could not recall the appearance of the resident's eye at the time. The family representative was told the condition had already been addressed, but there was no evidence of prior notification or assessment. Facility leadership and medical staff were unable to provide documentation supporting appropriate assessment, provider notification, or justification for the treatment initiated.