Failure to Timely Coordinate Vision Services per Care Plan
Penalty
Summary
The facility failed to coordinate and schedule timely vision services for one resident with a documented need for eye care. The resident’s face sheet showed admission to the facility prior to the events described, and the care plan dated 09/07/25 documented a diagnosis of hyperopia and included an intervention to arrange consultation with an eye care practitioner as required. Review of the electronic health record on 07/07/26 revealed no documentation that a vision appointment had been completed or scheduled. During an interview, the resident reported not having seen an eye doctor in over two years, stated that the facility was aware of this, and confirmed that lack of a vision appointment was one of his major concerns and that he wanted an appointment. The Scheduler, who is responsible for making resident appointments, stated that the resident had not had a vision consultation since admission and that the next appointment was scheduled for 07/01/26. She further stated that she did not call to schedule this appointment until 12/16/25, acknowledging that the appointment should have been scheduled sooner after the care plan update on 09/07/25 indicating the need for a vision appointment. The Social Services Assistant confirmed that the facility no longer had an in-house vision provider and agreed that the resident’s vision appointment should have been scheduled earlier than 12/16/25 following the care plan update.
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