Failure to Provide Vision Services and Corrective Lenses as Ordered
Penalty
Summary
Resident #29, who has a history of diabetes mellitus with proliferative diabetic retinopathy and severe cognitive impairment, was not provided with corrective lenses or vision care appointments as ordered by physicians. The resident's care plan included interventions to arrange consultations with an eye care practitioner as required, and there were physician orders for both glasses and scheduled eye appointments. However, medical record review showed no documentation that the resident attended the scheduled optometrist or ophthalmologist appointments, nor was there evidence that these appointments were rescheduled or reasons documented for the missed visits. Additionally, the resident's prescription for glasses had expired, and there was no follow-up to obtain a new prescription or replacement glasses after the resident's glasses were reported missing. Interviews with facility staff, including the DON and regional directors, confirmed a lack of documentation regarding the missed appointments and the absence of a facility policy related to vision appointments or following physician orders for ancillary services. The resident's POA reported the missing glasses and noted that the resident did not have them during a leave of absence or recent visits. Observations confirmed the resident was not wearing glasses, and staff were unaware of their absence. The facility was unable to provide evidence of compliance with physician orders for vision care or corrective lenses for this resident.