Failure to Reschedule Missed Ophthalmology Appointment After Unaccompanied Visit
Penalty
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.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.