F0684

D

Failure to Schedule Specialist Eye Appointment After Optometrist Referral

Rockford, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to schedule a specialist appointment as ordered and indicated for a visually impaired resident with Type 2 Diabetes Mellitus and diabetic retinopathy. The resident’s care plan dated 6/27/25 documented visual impairment related to these diagnoses. On 11/24/25, an in-house optometrist examined the resident and diagnosed bilateral cataracts, documenting that facility staff were to make an appointment with a glaucoma specialist. Subsequent review of the physician order report printed 12/9/25 showed no scheduled appointment with an optometrist specializing in glaucoma, and progress notes from 11/24/25 through 12/8/25 contained no documentation that such an appointment had been scheduled.

During an interview on 12/8/25, the resident reported that vision had significantly worsened over the past six months and stated that although an eye doctor had recommended seeing a specialist for cataracts or glaucoma, no appointment had been made. On 12/9/25, the Social Services Director stated she was not aware of the referral from the in-house optometrist. The Charge Nurse, who reported being responsible for making outside appointments once notified, stated she had not received a referral from the Social Services Director and was unaware of the need for a glaucoma specialist appointment. On 12/10/25, the Administrator stated the facility did not have a policy on scheduling outside appointments for residents.