Failure to Follow Up on Resident’s Need for Glasses and Vision Services
Penalty
Summary
The deficiency involves the facility’s failure to follow up on a documented need for eyeglasses for a resident who reported being unable to see properly. On 11/12/25, a Nurse Practitioner (NP #8) documented that the resident stated he/she could not see without glasses and that his/her glasses were broken. Subsequent documentation on 11/13/25 noted that staff continued to monitor the resident for falls as a safety precaution and that the resident had experienced several recent falls without injury. On 11/21/25, a note recorded that the resident was found on the ground in the courtyard, returned to his/her room, and assessed, at which time the resident complained of dizziness and blurred vision. Later on 11/21/25 at 9:08 PM, NP #8 documented that, per nursing staff, the resident fell out of his/her wheelchair onto his/her face while in the courtyard and that the resident felt dizzy and had poor baseline vision, needed to wear glasses, and did not have any glasses at the bedside. Review of the medical record showed no documentation that the resident was seen for vision services or that glasses were obtained. During interviews, the resident reported frequent falls and stated that glasses had not been replaced or found, and that staff said they would “get around to it.” A full-time RN on the unit reported not knowing anything about the glasses. NP #8 stated she had informed one of the nurses about the glasses but could not recall whom. The Medical Director acknowledged that the issue with the glasses and the resident’s complaints of dizziness and poor vision should have been followed up on and agreed with the surveyor’s findings.
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