Failure to Implement Vision Service Recommendations and Provide Updated Eyeglasses
Penalty
Summary
Surveyors identified that the facility failed to ensure a resident received proper treatment and assistive devices to maintain vision, despite an existing contract with a vision services company. The contract, effective December 14, 2018, required the company to arrange optometry services, including eye exams, medical eye evaluations, and fitting and ordering of eyeglasses, while the facility was responsible for coordinating necessary physician documentation. One resident with diagnoses including nonexudative age-related macular degeneration, dysphagia, and delusional disorders reported during an interview that his glasses were three years old and that he was unable to see out of them. His comprehensive care plan identified impaired vision with an intervention for ophthalmologist/optometrist consults as per orders. Clinical record review showed multiple vision consults with unimplemented recommendations. A consult dated November 26, 2024, documented bilateral nonexudative age-related macular degeneration and recommended scheduling a retinal specialist consult and obtaining new spectacles to maximize visual function. A February 5, 2025, consult recorded that the resident had not received the glasses from the November order, had not seen a retinal specialist, and was not receiving any prescribed eye drops, and again requested scheduling of the retinal specialist consult. A June 17, 2025, consult noted the resident still had not received new glasses or seen the retinal specialist and again requested scheduling for evaluation and treatment of possible choroidal neovascular membranes. During an interview, the DON acknowledged that the recommendations from the initial and February consults were missed, including during current facility ownership, and stated it was her expectation that contracted service recommendations be implemented or addressed by the physician if there was disagreement.
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