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:
Failure to Provide Scheduled Vision Services: A resident with ESRD, dialysis, HF, dysphagia, and use of glasses was consented for 360 Care vision services, but the scheduled vision visit did not occur as expected. The resident had also refused ophthalmic drops because they blurred vision, and the NP discontinued the medication. Staff reported the resident and daughter were waiting for the vision team, but the team was packing up and said the resident would not be seen; the visit record later stated the resident refused services, and follow-up emails sought another appointment.
A resident with chronic angle-closure glaucoma and stroke history repeatedly reported eye pain and headaches, but vision follow-up was delayed while staff said she was on the eye doctor list and Medicaid approval was pending. Records showed ongoing complaints, reduced vision with glasses, and later optometry findings of dangerously high IOP that led to urgent ophthalmology treatment and loss of vision in one eye. The DON said she was unaware of the eye issue until the family arranged the appointment, and the administrator stated the resident should have been seen.
Failure to Provide Access to Hearing Aids: A resident with dementia and documented hearing loss was not provided access to her hearing aids, which were stored in the SSD’s file cabinet. The resident stated she could not hear when spoken to, a CNA confirmed she had hearing problems and often needed words repeated, and the SSD said the hearing aids were not known to staff, may not have been working, and were supposed to be checked by ENT. The resident’s record and belonging list identified two hearing aids, but staff were unaware she had them.
A resident with hypertensive retinopathy was observed without eyeglasses, and she stated she had an eye appt but had not received the glasses she was told were coming. The optometry consult documented that bifocal eyeglasses were ordered, but the facility had no documentation that the glasses were received or provided. Social Services stated the monthly eyeglass shipment did not include the resident’s glasses and that no follow-up had been made with the optometry provider about the delay.
Failure to Schedule Ordered Cataract Extraction: A resident with legal blindness and other diagnoses was ordered for bilateral cataract extraction, but the facility did not make the ophthalmology appointment or document that it was rescheduled. The resident reported repeated unanswered questions about why the cataracts had not been removed, while the SW said the facility could not contact the family for transport and did not follow through on rescheduling. The DON and NHA confirmed the appointment had not been made.
A facility failed to ensure two residents received ordered hearing aids and failed to arrange an ophthalmology consult for a resident with worsening vision. One resident was observed with both hearing aids out of the ear canal despite an order for daily use, another was found without hearing aids during the morning pass and said she could not hear well, and the SSD stated an ophthalmology visit was missed because insurance authorization had not been completed.
Failure to Provide Scheduled Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided to a resident admitted with end-stage renal disease, renal dialysis, heart failure, dysphagia, and a dialysis fistula. The resident’s admission packet included consent for 360 Care ancillary services for audiology, vision, and podiatry, and the initial MDS indicated the resident used glasses and required hearing aids. In April 2026, the resident was treated with ciprofloxacin ophthalmic drops for conjunctivitis, but the resident refused the drops because they affected vision and made the eyes blurry; the NP discontinued the medication after the refusals and later prescribed lubricating eye drops after discussing treatment options with the resident’s family. An email from the Social Service Director requested that 360 Care add the resident for a vision visit and marked the resident as a priority, but there was no evidence of confirmation before the scheduled visit. The resident was listed as not seen on the 360 Care visit report, which noted the resident refused services. The Social Service Director later emailed again stating the resident had not been seen despite the family being present and reporting that the resident was not seen, and followed up again the next day seeking an emergent appointment. During interviews, the Social Service Director and Administrator stated the resident and daughter were waiting for the vision team, but the team was packing up and said they would not see the resident. The Administrator also reported that 360 Care management later stated the resident had refused, while the daughter had already left upset after the missed visit.
Failure to Provide Timely Vision Services for Resident with Glaucoma
Penalty
Summary
The facility failed to ensure vision services were provided for one resident with a history of chronic angle-closure glaucoma in both eyes, including severe disease in the left eye. The resident was admitted and later readmitted with diagnoses that included stroke and chronic angle-closure glaucoma, and was cognitively intact. The record showed repeated requests for Tylenol for headaches and eye pain over many months, and a progress note documented that the resident could read larger print but not average-size print with glasses in place, with a memo sent to social work for the next vision follow-up. The resident told surveyors she had narrow angle glaucoma, had laser surgery in 2015, and was supposed to have seen an eye doctor after her stroke in 2024 but did not see one until January 2026, when her eye pressures were very high and she lost vision in her left eye. Social work stated the resident wanted to see the eye doctor for new glasses and that Medicaid approval took about a year, which delayed the visit; when asked why she was not seen after Medicaid was approved, social work had no explanation. The business office manager stated Medicaid was approved on 5/5/25. The record included an H&P noting eye pain and that the resident was on the list to be seen by optometry. An optometry consult later showed dangerously high intraocular pressures and reduced vision, with an immediate referral to ophthalmology for treatment of narrow angles. Ophthalmology documented same-day laser treatment and very high pressures, and a later consult described chronic angle closure in both eyes with end-stage left eye vision loss. The DON stated she had not known about the eye issues until the family took the resident to the eye doctor and surgery was needed, and the administrator stated the resident should have been seen.
Failure to Provide Access to Hearing Aids
Penalty
Summary
The facility failed to provide one sampled resident with access to her hearing aids, which were stored in the Social Service Director’s file cabinet. Resident 92 had diagnoses including encephalopathy, dementia, anxiety, and generalized muscle weakness. Her record showed an order for ENT and audiology consultation and treatment as needed, and the MDS indicated she had adequate hearing, did not use hearing aids, and was sometimes able to express wants and understand others. During interview, the resident stated she could not hear when spoken to and said it would be great to be seen by a hearing doctor. Staff interviews confirmed the hearing problem and the lack of hearing aid use. A CNA stated the resident had problems with hearing, often asked staff to repeat words, and did not use hearing aids. The SSD stated the resident had hearing aids stored in the SSD’s file cabinet, but the SSD did not know how to turn them on and was not sure if they were working; the SSD also stated they were supposed to be checked by an ENT doctor and that the resident would not be able to express her needs and wants or communicate if not provided with the hearing aids. The ADON stated no staff in the facility was aware the resident had hearing aids. ENT documentation showed diminished hearing and hearing loss in the left ear, and the resident belonging list identified two hearing aids. The facility’s policy for hearing aid care required documentation of checks and battery replacement, but the report did not show that the resident’s hearing aids were being provided or used.
Failure to Provide Ordered Eyeglasses
Penalty
Summary
The facility failed to ensure an assistive optical device was provided for Resident #57, who had a diagnosis of hypertensive retinopathy. During observation, the resident was watching television and was not wearing eyeglasses. The resident stated she had an eye appointment in January but had not received the glasses she was told would be coming for her. The optometry consultation dated 01/21/2026 documented that bifocal eyeglasses were ordered. Staff in Social Services stated the facility’s optometrist visits monthly and eyeglasses are typically delivered monthly, but no eyeglasses for Resident #57 were included in the last shipment. Staff also stated she had not contacted the optometry provider to determine the status of the eyeglasses. The record contained no documentation that the ordered eyeglasses had been received by the facility or provided to the resident, and no documentation that staff followed up with the optometry provider regarding the delayed delivery.
Failure to Schedule Ordered Cataract Extraction
Penalty
Summary
The facility failed to make an ophthalmology appointment as ordered for one resident, R505, who was reviewed for coordination of outside physician appointments. R505 was observed lying in bed with the TV on and reported that the facility had not scheduled the cataract extraction, stating that the doctor said vision would improve after cataract removal, that the resident had been set up to go but never returned to the eye doctor, and that repeated questions to staff had not produced an answer about why the cataracts had not been removed. Record review showed R505 was re-admitted with diagnoses including peripheral vascular disease and legal blindness. An Optometry Order Form dated 12/9/25 documented that the patient had been scheduled at a named eye center for bilateral cataract extraction and should be rescheduled when possible, but there was no further documentation showing the appointment was made. The SW stated the facility tried to set up an appointment but could not contact the family to assist with transport and did not know what happened afterward, and acknowledged the appointment should have been rescheduled. The DON and NHA both confirmed the cataract extraction appointment had not been made and could not explain why it was not done.
Failure to Provide Hearing Aids and Arrange Ophthalmology Consultation
Penalty
Summary
The facility failed to ensure proper assistive devices were provided for hearing and vision services for three sampled residents. For Resident 43, the record showed diagnoses including decreased hearing and dementia, and the physician ordered hearing aids to be applied daily or as needed, turned on in the morning, and turned off at night. The care plan also included interventions to ensure the availability and functioning of the hearing aids and to monitor hearing impairment. During a concurrent observation and interview, Resident 43 was found with both hearing aids not inserted in the ear canal, and the RN stated nursing staff should monitor that the hearing aids remain in place throughout the day so the resident can hear. For Resident 79, the record showed the resident wore hearing aids and had potential communication problems related to hearing impairment. The physician ordered hearing aids to be placed in the ears every day shift and removed, stored, and charged every evening shift. During interview, LVN 7 stated the morning nurse administers the hearing aids and the evening Charge Nurse collects them at bedtime. During a concurrent observation and interview, Resident 79 was sitting in a wheelchair listening to music without hearing aids, stated, "I can't hear well, please increase the volume," and LVN 7 then stated the hearing aids had not been administered during that morning medication pass and should have been provided as ordered. The facility policy also stated staff are to assist residents with insertion of hearing aids and monitor function and care. For Resident 87, the record showed impaired visual function, with the resident reporting vision loss in the left eye and diminishing vision in the right eye, and a history of retinal detachment in the left eye. The physician order summary included that the resident may see an ophthalmologist, and the care plan called for scheduling consultations with eye specialists as needed. The Social Service assessment indicated the resident was referred to ancillary services. However, the ophthalmology appointment was not completed because insurance authorization was required beforehand, and the resident was not seen when the ophthalmologist was at the facility. The SSD stated she missed this step and accepted full responsibility, and the DON stated social services are responsible for arranging and scheduling referrals for ancillary services.
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