Failure to Assess and Monitor Eye Condition and Contact Lens Use Leading to Severe Ocular Injury
Summary
The deficiency involves the facility’s failure to comprehensively assess, treat, and monitor a resident’s eye and vision needs, including the use of contact lenses, which led to an acute change in condition and hospitalization. The resident was admitted with multiple diagnoses including history of TIA and cerebral infarction without residual deficits, a C2 spinal cord lesion with tetraplegia, systemic lupus erythematosus, major depressive disorder, and type 2 diabetes with neuropathy. On admission, the MDS assessment documented that the resident’s vision was adequate and that she denied using corrective lenses or contacts, and no vision or visual appliance care plan was initiated. Later documentation from an eye care physician noted that the resident wore contact lenses and had new bifocals ordered, and the quarterly MDS documented use of corrective lenses including contacts or glasses, yet the care plan was never updated to address vision needs or the use and management of visual appliances. The resident developed left eye redness and drainage and was diagnosed with conjunctivitis by a nurse practitioner, who ordered antibiotic eye drops. The NP’s note did not specify when symptoms began or include the resident’s input about symptom development. From the time of this diagnosis through several days afterward, nursing progress notes did not document ongoing assessments or monitoring of the left eye, despite the initiation of treatment. During this period, the MAR showed administration of hydrocodone-acetaminophen for pain on multiple occasions without documentation of the pain’s location. According to NIH and CDC information cited in the report, bacterial conjunctivitis treated with antibiotics should show clinical improvement within about 24 hours, and lack of improvement warrants further evaluation; however, there was no documented reassessment or escalation when the resident’s condition did not improve. On a subsequent morning, an RN documented that the resident’s left eye was red, the eyelid was matted shut, and there was copious yellow purulent drainage, with redness extending around the eye and cheek. A contact lens was observed in the left eye, and the RN was unable to remove it despite multiple attempts with sterile saline irrigation and warm compresses. An NP was contacted and ordered transfer to the ED, but before transfer occurred, an aide removed the contact lens. The resident then stated she did not want to go to the ED, the NP was notified, and orders were given to continue conjunctivitis treatment; however, there was no documented licensed nurse assessment of the eye after the contact was removed and no documentation of education regarding the NP’s ED transfer order when the resident refused. From that point until early the next morning, there was no written evidence of eye assessments or monitoring, even though the resident later reported increased left eye pain and continued purulent drainage. Pain medication and warm compresses were provided, but there was no comprehensive assessment or timely notification of the NP or physician until the resident complained of pain and vision loss, at which time she was finally sent to the ED. Hospital records documented a corneal ulcer and infection associated with prolonged contact lens wear, and the resident ultimately underwent enucleation of the affected eye. Additional interviews and record reviews showed that staff were not consistently aware that the resident used contact lenses, despite documentation in the eye care note and quarterly MDS. The DON confirmed there was no vision-related care plan even after bifocals were delivered. The MDS nurse stated that the initial assessment recorded no use of visual appliances based on the resident’s report, and that no care plan was initiated after the quarterly MDS identified corrective lens use. Nursing and therapy staff reported being unaware of contact lens use, and some recalled the resident mentioning eye irritation weeks before the acute episode, with this information only passed informally to an aide. On the morning when the contact lens was reportedly removed, the RN acknowledged not reassessing the eye afterward and leaving at the end of the shift. The on-call NP reported being informed via video call that the contact had been removed and instructed staff to continue eye drops and monitor for changes, but subsequent nursing documentation did not show the required monitoring or timely response to worsening symptoms, culminating in the resident’s transfer to the hospital with severe eye pain, purulent drainage, and vision loss. The report also notes that the facility’s own policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family or representative when there was a significant change in condition, including deterioration in health or clinical complications. Despite this policy, the record lacked evidence of timely physician/NP notification and comprehensive assessment at several key points when the resident’s eye condition worsened, including increased pain, persistent purulent drainage, and onset of vision loss. A family concern form documented that the resident’s family believed the resident had been in pain for several days, questioned why the NP did not identify the contact lens earlier, and asserted that the nursing process was not followed when the resident reported eye discomfort and was only given pain medication. Collectively, these documented actions and omissions formed the basis for the cited deficiency related to failure to provide appropriate treatment and care according to orders, and to comprehensively assess and monitor the resident’s eye condition and visual appliance use.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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