Failure to Reschedule Missed Ophthalmology Appointment After Unaccompanied Visit
Summary
The deficiency involves the facility’s failure to ensure a resident obtained ordered ophthalmology services after a missed appointment. The resident had diagnoses including type 2 diabetes, glaucoma, and coronary artery disease, and a physician progress note documented bilateral eye burning. On the following day, the physician ordered a referral to an outpatient ophthalmologist, along with Refresh Tears ophthalmic solution four times daily for dry eyes and PRN Tylenol for pain. A quarterly MDS showed the resident had moderate cognitive impairment, was coded as having adequate vision without corrective lenses, and was coded as not having pain or receiving pain interventions. A transport requisition was completed for an eye appointment at an outpatient office, and the contracted Transportation Aide reported picking up the resident and signing him in for the appointment. Shortly after leaving, the outpatient office called the Transportation Aide to report that the resident could not be seen without someone accompanying him. The Transportation Aide called the facility and was told there was no one available to accompany the resident. When the Transportation Aide returned to the outpatient office, she learned the resident was having a medical emergency and had been transported by ambulance to the ED. Later that day, she picked the resident up from the ED and returned him to the facility. Record review showed no evidence that the missed ophthalmology appointment was ever rescheduled. The Medical Supplies Personnel, who maintained a calendar and transportation requisition forms, had no record of any upcoming eye appointment for the resident. The MARs indicated the ordered eye drops were administered four times daily and PRN Tylenol was given once for a reported pain level of 4/10, with all other documented pain assessments at 0. Attempts to interview the resident about his vision and eye appointments were unsuccessful. The Unit Manager confirmed the resident did not receive ophthalmology services on the day of the missed appointment and stated she had called the eye clinic and was waiting for a call back to reschedule, but there was no documentation of a new appointment. The Medical Director and Administrator both stated their expectations that specialty referrals and any missed appointments be scheduled or rescheduled so residents receive needed medical services, which did not occur in this case.
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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