Failure to Act on Ophthalmology Referral and Coordinate Timely Eye Care
Summary
The deficiency involves the facility’s failure to act upon a provider’s ophthalmology referral and to timely coordinate specialty eye care for one resident with a chronic and worsening left eye infection. The resident had a history of schizoaffective disorder, morbid obesity, and prior stroke, with moderately impaired decision-making requiring cues and supervision. In early April 2025, a physician documented bilateral eye irritation and redness consistent with conjunctivitis. On 5/13/2025, an NP/PA documented chronic conjunctivitis and ordered a culture of the left eye drainage before starting antibiotics. A physician order dated 5/17/2025 directed staff to obtain the left eye drainage culture that day, and the 5/22/2025 bacteriology report showed 3+ MRSA in the eye culture. On 6/26/2025, a physician progress note documented continued management of conjunctivitis with recent treatment having no to minimal effect and indicated that new orders and an ophthalmology referral were given. However, review of the EMR showed no corresponding physician order for an ophthalmology referral at that time. The facility’s own staff later acknowledged that the 6/26/2025 referral was not found in the EMR and that there had been an ongoing issue with missed orders around that period. The former scheduler stated he likely was not informed of the June referral, and the Unit Manager/RN stated she was unsure where in the process the June referral broke down, but confirmed that the ophthalmology appointment was not attempted to be scheduled until months later. During the months following the June referral, nursing documentation showed persistent and progressively worsening signs and symptoms of left eye infection. Between early July and mid-September, multiple infection/signs and symptoms notes described green mucus drainage at the inner canthus, crusting despite cleansing and eye drops, bilateral eye redness with drainage, ongoing redness with drainage, repeated scleral injection, increased redness, tenderness, and purulent drainage, the eye being closed shut with thick yellow drainage and pain, and swelling around the eye. On 9/15/2025, a physician order was entered for an ophthalmology appointment “ASAP” related to chronic eye infections. The ophthalmology clinic later confirmed that the first contact from the facility to schedule this resident was not until 9/25/2025, despite the clinic’s ability to see acute eye pain cases within about three days. When the resident was finally transported by EMS to the ophthalmology clinic, staff there documented a months-long history of red, irritated eye with purulent discharge, worsening pain and redness, and immediate concern for bacterial cellulitis and possible sepsis, leading to referral to an ER. The ER documented septic shock and severe eye infection, and the specialty hospital discharge summary confirmed preseptal cellulitis, bacterial keratitis of the left eye, and sepsis present on admission. At the time of the surveyor’s observations in February 2026, the resident’s left eye remained swollen, limiting visualization of the eye and partially blocking vision, and the resident reported that vision in the left eye was still “a little blurry.” The facility’s DON could not explain why there were two separate ophthalmology referrals, one in June and one in September, and acknowledged uncertainty about what happened with the earlier referral. The Unit Manager/RN described the facility’s process as requiring that referrals be transcribed into the EMR as orders so that the transport driver can schedule appointments, but confirmed that the June referral was missed. The ophthalmology clinic’s receptionist confirmed that the facility did not contact the clinic about this resident until late September, despite the chronic and worsening eye condition documented over the preceding months.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with DM2, COPD, and chronic pain was seen by the facility eye doctor and found to have visually significant cataracts in both eyes, with a recommendation for cataract surgery and an Ophthalmology consult. The resident wanted to proceed, but no referral or appointment was scheduled. The NP, scheduler, and DON each stated they were unaware of the completed referral, and the DON said the recommendation had been overlooked.
Failure to Provide Ordered Vision and Hearing Services: The facility did not ensure ordered eye and ear treatments were provided for three residents. One resident with dry eye symptoms did not receive prescribed erythromycin ointment or artificial tears, another resident with occluding cerumen did not receive the ordered ear drop regimen or irrigation, and a third resident with dry eye syndrome had Restasis discontinued without explanation and did not receive ordered artificial tears. The DON confirmed the missing treatments and lack of documentation.
A resident who wore glasses on admission lost them while in the facility, but the care plan did not address her need for corrective lenses and staff did not take timely steps to locate or replace them. The NHA and DON reported no knowledge of or investigation into the missing glasses, and repeated observations showed the resident without glasses.
Failure to ensure hearing services and devices were properly managed for two residents. One resident with Parkinson's Disease and a cognitive communication deficit had an audiology consult showing cerumen occluding both ears and moderate to severe sensorineural hearing loss, but the recommended Debrox treatment was not implemented when first identified. Another resident with HTN and CKD reported being very hard of hearing, was observed without hearing aids or amplifiers in place, and had MDS data showing highly impaired hearing and hearing appliance use, yet the care plan and physician orders did not document a hearing device.
Failure to complete audiology referrals for two residents. One resident had moderate hearing difficulty and impaired communication on the care plan, and another resident wanted a hearing test after speaking with the MD. Both had MD orders for audiology referrals, but the EHR did not show the referrals were initiated or completed, and staff could not find documentation that they had been done.
A resident with cerebral palsy, diabetes, and obesity continued to report hearing difficulty after an audiology exam recommended cerumen management for both ears and PCP removal of deep wax. Although the resident was seen twice afterward by the PCP and/or NP, the DON stated the recommendation had been logged in the physician's book but was not addressed by the physician.
Failure to Schedule Recommended Cataract Surgery Consult
Penalty
Summary
The facility failed to follow through with an eye physician’s recommendation for an Ophthalmology consult for cataract surgery for Resident #57. Resident #57 was admitted with diagnoses including type 2 diabetes, COPD, and chronic pain, and the quarterly MDS indicated she was cognitively intact, dependent on staff for ADLs, and coded for adequate vision. A facility vision clinic optometrist note dated 3/03/26 documented that cataracts were visually significant in both eyes, recommended cataract surgery, an Ophthalmology consult, and informing the facility physician, and noted that Resident #57 wanted to proceed with surgery. During interview, Resident #57 stated she had been told by the facility eye doctor that she needed cataract surgery and that a referral was supposed to be made, but no appointment had been scheduled. The NP stated she was not aware of previous orders for cataract surgery and agreed the referral should have been completed as ordered. The scheduler stated she had not received any orders or referrals for the resident to be seen for cataract surgery. The DON stated she was not aware of the prior referral recommendation and said the report from the in-house eye clinic should have been reviewed, nursing staff notified, the facility physician informed, and any needed orders obtained; she stated the recommendation had been overlooked. The Administrator stated he expected nursing staff to review physician orders and ensure appointments and referrals were scheduled in a timely manner.
Failure to Provide Ordered Vision and Hearing Services
Penalty
Summary
The facility failed to ensure residents received ordered vision and hearing services for three residents reviewed for those needs. Resident #22, admitted with diagnoses including COPD, CHF, personality disorder, and morbid obesity, had a vision exam showing dry eye symptoms, crusting, and red flaky skin on the lashes. The eye physician recommended erythromycin ointment to both eyes twice daily for 10 days and artificial tears to both eyes twice daily, but there was no evidence either medication was ever given. The DON confirmed there was no evidence the resident received the recommended eye medications, and the resident stated she wanted the drops because the fan in her room made her eyes dry. Resident #11, admitted with diagnoses including paranoid schizophrenia, morbid obesity, diabetes, and chronic venous hypertension, had audiology consults showing completely occluding cerumen in both ears. The audiologist documented that the wax was too hard and impacted to remove safely and required an ear drop regimen with subsequent irrigation once daily for three days, but there was no evidence the resident ever received the ordered ear drops or irrigation. Resident #3, admitted with diagnoses including acute kidney failure, acute respiratory failure, diabetes, and morbid obesity, had a vision exam noting dry eye syndrome and recommending continued Restasis twice daily in both eyes and artificial tears twice daily in both eyes. The MAR showed Restasis was discontinued and there was no documentation explaining why, and there was no evidence the artificial tears were given. The DON confirmed there was no evidence the resident received the eye drops as recommended and did not know why Restasis was discontinued.
Failure to Assist Resident With Replacement Glasses
Penalty
Summary
The facility failed to assist a resident in gaining access to vision services by not including her use of glasses in the plan of care and not implementing timely measures to obtain replacement glasses after they were lost. The resident was admitted with glasses and her electronic medical record profile picture showed her wearing them, and a nursing admission progress note documented that she had a corrective vision appliance on admission. Her husband later reported that she wore glasses but had lost them while living at the facility and staff could not find them. Review of the available care plans showed no evidence that the resident’s need for glasses was incorporated into her plan of care. The Nursing Home Administrator and DON stated they had no knowledge of or investigation into the missing glasses, and observations on multiple dates showed the resident without glasses.
Failure to Provide Hearing Treatment and Hearing Devices
Penalty
Summary
The facility failed to ensure that two residents received proper treatment and assistive devices to maintain hearing abilities. One resident with Parkinson's Disease and a cognitive communication deficit reported hearing loss and was awaiting hearing aids. An audiology consultation completed after the resident reported hearing loss found cerumen occluding both ears and moderate to severe sensorineural hearing loss in both ears. The audiologist recommended a 7-day treatment plan using a softening agent such as Debrox, but the report did not show that the primary physician reviewed the recommendations, and the resident did not receive the recommended treatment when it was first identified. A second resident with hypertension and chronic kidney disease stated that she was very hard of hearing and had difficulty communicating because of it, and she said she had hearing aids but left them in the dining room. Observation showed she did not have hearing aids or amplifiers in place during the interview. Her quarterly MDS indicated highly impaired hearing and that a hearing aid or other hearing appliance was used, but her care plan did not include any intervention or documentation for hearing device use, and her physician orders did not include an order for a hearing device. An audiology consult also documented moderate to severe sensorineural hearing loss and that she would benefit from hearing aids.
Failure to Complete Audiology Referrals
Penalty
Summary
The facility failed to ensure physician orders for audiology referrals were followed for 2 residents reviewed for hearing devices. Resident 2’s quarterly MDS dated 07/03/2026 showed moderate difficulty hearing, and the care plan dated 07/10/2026 identified impaired communication related to being hard of hearing. A physician order dated 04/03/2026 documented a referral to audiology, but review of the EHR did not show that the referral was initiated or completed. Resident 3’s quarterly MDS showed intact thinking and memory. During an interview on 07/07/2026, Collateral Contact 1 stated Resident 3 wanted a hearing test to determine whether they were hard of hearing and had already spoken with the doctor, but nothing had happened to get the resident tested. A physician order dated 04/03/2026 also showed a referral to audiology, and further review of the EHR did not show that the referral was initiated or completed. Staff F stated the facility coordinated referrals for residents to be seen by providers, and Staff B and Staff A stated they could not find documentation that the audiology referrals for Resident 2 and Resident 3 had been completed.
Failure to Follow Up on Audiology Recommendations
Penalty
Summary
The facility failed to follow up on audiology recommendations for R129, a resident admitted with diagnoses including cerebral palsy, diabetes, and obesity who was cognitively intact and required assistance with ADLs. On 07/14/2026, R129 was observed lying in bed and stated they had been seen by audiology but continued to have difficulty hearing and had to speak louder because they could not hear themselves. The medical record showed an audiology exam dated 6/17/26 that recommended cerumen management for both ears and noted deep wax still present with a need for PCP removal. The record also showed the resident had been seen twice after that audiology visit by the PCP and/or NP, but the recommendations were not addressed. The DON stated the recommendations had been logged in the physician's book but had not been addressed by the physician as they should have been.
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