Failure to Act on Ophthalmology Referral and Coordinate Timely Eye Care
Summary
The deficiency involves the facility’s failure to act upon a provider’s ophthalmology referral and to timely coordinate specialty eye care for one resident with a chronic and worsening left eye infection. The resident had a history of schizoaffective disorder, morbid obesity, and prior stroke, with moderately impaired decision-making requiring cues and supervision. In early April 2025, a physician documented bilateral eye irritation and redness consistent with conjunctivitis. On 5/13/2025, an NP/PA documented chronic conjunctivitis and ordered a culture of the left eye drainage before starting antibiotics. A physician order dated 5/17/2025 directed staff to obtain the left eye drainage culture that day, and the 5/22/2025 bacteriology report showed 3+ MRSA in the eye culture. On 6/26/2025, a physician progress note documented continued management of conjunctivitis with recent treatment having no to minimal effect and indicated that new orders and an ophthalmology referral were given. However, review of the EMR showed no corresponding physician order for an ophthalmology referral at that time. The facility’s own staff later acknowledged that the 6/26/2025 referral was not found in the EMR and that there had been an ongoing issue with missed orders around that period. The former scheduler stated he likely was not informed of the June referral, and the Unit Manager/RN stated she was unsure where in the process the June referral broke down, but confirmed that the ophthalmology appointment was not attempted to be scheduled until months later. During the months following the June referral, nursing documentation showed persistent and progressively worsening signs and symptoms of left eye infection. Between early July and mid-September, multiple infection/signs and symptoms notes described green mucus drainage at the inner canthus, crusting despite cleansing and eye drops, bilateral eye redness with drainage, ongoing redness with drainage, repeated scleral injection, increased redness, tenderness, and purulent drainage, the eye being closed shut with thick yellow drainage and pain, and swelling around the eye. On 9/15/2025, a physician order was entered for an ophthalmology appointment “ASAP” related to chronic eye infections. The ophthalmology clinic later confirmed that the first contact from the facility to schedule this resident was not until 9/25/2025, despite the clinic’s ability to see acute eye pain cases within about three days. When the resident was finally transported by EMS to the ophthalmology clinic, staff there documented a months-long history of red, irritated eye with purulent discharge, worsening pain and redness, and immediate concern for bacterial cellulitis and possible sepsis, leading to referral to an ER. The ER documented septic shock and severe eye infection, and the specialty hospital discharge summary confirmed preseptal cellulitis, bacterial keratitis of the left eye, and sepsis present on admission. At the time of the surveyor’s observations in February 2026, the resident’s left eye remained swollen, limiting visualization of the eye and partially blocking vision, and the resident reported that vision in the left eye was still “a little blurry.” The facility’s DON could not explain why there were two separate ophthalmology referrals, one in June and one in September, and acknowledged uncertainty about what happened with the earlier referral. The Unit Manager/RN described the facility’s process as requiring that referrals be transcribed into the EMR as orders so that the transport driver can schedule appointments, but confirmed that the June referral was missed. The ophthalmology clinic’s receptionist confirmed that the facility did not contact the clinic about this resident until late September, despite the chronic and worsening eye condition documented over the preceding months.
Penalty
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Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
A resident with glaucoma and intact cognition requested to see an ophthalmologist and was told she had been placed on a list, but no follow-up occurred and no appointment was arranged. Her records documented glaucoma, use of corrective lenses, and a care plan for impaired visual function. A CNA stated she would report such requests to a nurse and was unsure if the prior process for in-house eye care was still in place. An LPN confirmed the resident’s request from a couple of months earlier, noted that the vision care logbook could not be located, and reported the request to the prior DON during a time without a Unit Manager. The interim DON described the standard process for arranging vision exams and acknowledged that it did not result in the expected access to services for this resident, despite a policy affirming residents’ rights to access needed services.
A resident with ataxia and significant assistance needs had a provider-ordered ophthalmology referral for a skin tag under the left eye, but the appointment was not arranged. The resident said the issue was discussed with the doctor and nothing happened afterward. Staff stated the MRD handled referrals and transportation, but she had not acted on the order and said it may have been lost in paperwork; the DON and NP expected the referral to have been completed by then.
A resident with dementia and documented impaired vision had an active physician order for an eye health and vision consult and a care plan intervention to arrange an eye care practitioner consultation, but no optometry appointment or exam was ever documented during the entire stay. The resident’s responsible party reported the resident had not had an eye exam and could not see with their glasses, and the ADON confirmed there was no record of any eye exam. The resident’s prescription glasses were found in a bedside drawer, and the DON acknowledged the resident should have had an optometry appointment. This occurred despite facility policy requiring social services and nursing to arrange ordered medical referrals.
Failure to Follow Up After Ophthalmology Appointment: A resident with DM, impaired vision, and moderate cognitive impairment reported weeks of left eye dryness and pain, saying he had told multiple staff and requested eye drops but felt ignored. Records showed an ophthalmology visit for bilateral eye pain, floaters, and blurry vision, but there was no documentation that the resident returned from the appointment or that any visit note or new orders were received and carried out. Staff confirmed the lack of follow-up documentation and that the resident's eye complaints were not addressed.
A resident with macular degeneration and moderate cognitive impairment had a care plan directing staff to arrange eye care consultations and a written consult order to schedule an appointment with a cataract surgeon. The resident’s family reported missed eye appointments due to lack of facility follow-up. The Medical Records Director admitted he had not scheduled the surgery because he was backed up with other work, while the Administrator was unaware of the order and the Medical Director stated he expected Social Services to arrange the appointment and transportation. As a result, the facility did not coordinate the ordered vision services in accordance with its own policy.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Failure to Ensure Resident Access to Vision Services
Penalty
Summary
The facility failed to ensure access to vision services for a resident with glaucoma who had intact cognition and used corrective lenses. The resident reported that she had requested to see an ophthalmologist months earlier and had been told she was placed on a list, but no follow-up occurred and she did not know why the request had not been addressed. Her admission record documented a diagnosis of glaucoma, and her quarterly MDS showed a BIMS score of 15/15 and use of corrective lenses. Her active care plan identified impaired visual function related to glaucoma, with interventions limited to observing, documenting, and reporting signs or symptoms of acute eye problems. Staff interviews revealed gaps in the process for arranging vision care. A CNA recalled that an eye doctor used to see residents but was unsure if that process was still in place and stated she would report any resident request for an eye doctor to the nurse, with the Unit Manager typically arranging appointments. An LPN confirmed that the resident had requested to see an ophthalmologist a couple of months earlier, but when the LPN attempted to document this in a logbook for vision care needs, the logbook could not be found. The LPN reported the request to the previous DON during a period when there was no Unit Manager. The interim DON described the facility’s process for vision exams, including notifying a nurse or supervisor, determining whether to use an in-house optometrist or an outpatient appointment, and having designated staff arrange appointments and transportation, but stated she was not aware of this resident’s request and acknowledged that the process did not achieve the expected outcome for the resident. The facility’s Resident Rights Policy states that residents have the right to communication with and access to services inside and outside the facility, which was not ensured in this case.
Failure to Follow Up on Ophthalmology Referral
Penalty
Summary
The facility failed to ensure follow-up on a provider-ordered ophthalmology referral for a resident who was cognitively intact and required substantial to maximal assistance with transfers and mobility. The resident’s diagnoses included ataxia and need for assistance with personal care. A provider visit note documented that the resident asked about a small yellowish skin tag under the left eye, and an ophthalmology appointment was ordered for the skin tag under the left eye on 1/20/26. During observation and interview, the resident stated he had discussed the skin tag with the doctor and was told they would look into getting it removed, but that never happened. Staff interviews showed the medical records director was responsible for arranging referrals and transportation, and the DON expected routine and non-routine appointments to be scheduled timely. The medical records director stated she had just seen the ophthalmology referral the prior week and had not made any arrangements yet, explaining it may have been lost in paperwork while reorganizing her office. The DON and NP both stated the appointment should have been arranged and completed by then, and the facility did not provide a policy on appointment scheduling or provider orders.
Failure to Arrange Timely Optometry Services for Resident With Impaired Vision
Penalty
Summary
The facility failed to assist a resident with impaired vision in obtaining timely optometry care despite documented need and physician orders. The resident, admitted in 2020 with dementia and documented impaired vision on the MDS dated 3/15/20, had corrective lenses and an order dated 3/5/20 for an eye health and vision consult with follow-up treatment as indicated. The resident’s care plan dated 11/11/22 identified impaired visual function and included an intervention to arrange consultation with an eye care practitioner as required, with a goal for the resident to maintain optimal quality of life within the limitations of visual function. During interviews, the resident’s responsible party reported that the resident had not had an eye exam and could not see with their glasses. The ADON confirmed there was no documentation or proof that the resident had an eye exam during their entire stay. Observation showed the resident’s prescription glasses stored in the bedside drawer rather than in use. The DON stated the resident should have had an optometry appointment during their stay and that this was important for safety. The facility’s policy on social services referrals required that referrals for medical services be based on physician evaluation or resident need and that social services collaborate with nursing or other disciplines to arrange ordered services, but this process was not carried out for the resident’s ordered eye care consult.
Failure to Follow Up After Ophthalmology Appointment
Penalty
Summary
The facility failed to ensure that Resident 53 received proper treatment after an ophthalmology appointment. Resident 53 was admitted with diagnoses including diabetes mellitus, difficulty walking, and depression, and the record also noted fluctuating capacity to understand and make decisions and moderate cognitive impairment. The care plan identified impaired vision and eye-related concerns, including the need to monitor for irritation, redness, dryness, and to arrange consultation with an eye care practitioner as required. During observation and interview, Resident 53 reported dryness in the left eye for 7 weeks and described it as feeling like a scratch on the skin. The resident stated he had eye surgery in the past, had used eye drops previously, and had complained to multiple staff about the dryness and requested eye drops, but felt ignored. On concurrent interview, the resident again stated that he had informed multiple staff that nothing had been done and requested eye drops for relief. Record review and staff interviews showed that Resident 53 had an ophthalmology appointment, but there was no documentation that he returned from the appointment or that any visit note or new orders were received and carried out. LVN staff stated that the appointment result was not available in the chart and that there was no order for eye drops. The visit note from the ophthalmology appointment documented complaints of pain in both eyes, floaters, blurry vision, and pain for 6 months, with the resident using over-the-counter dry eye drops. Staff interviews also confirmed that documentation was required when residents left for and returned from appointments, and that the resident's needs were not addressed.
Failure to Coordinate Ordered Cataract Surgery for a Visually Impaired Resident
Penalty
Summary
The facility failed to coordinate and arrange ordered vision services for one resident with known visual impairment. The resident, admitted in 2022, had a medical history of macular degeneration and a care plan focus area for impaired visual function, with interventions directing staff to arrange consultation with an eye care practitioner as required. A quarterly MDS assessment showed the resident had moderate cognitive impairment (BIMS score of 11) and documented vision as adequate without corrective lenses, while the care plan still identified impaired vision related to macular degeneration. A consult form dated 03/10/2025 instructed staff to schedule an appointment with a cataract surgeon for this resident. Despite this written directive, the appointment and surgery were not scheduled. The resident’s family member reported that the resident’s eye appointments had been missed because no one at the facility followed up on them. The Medical Records Director acknowledged he had not recently called to schedule the surgery, stating he was backed up with other work. The Administrator reported she was unaware of the order to schedule cataract surgery for the resident. The Medical Director stated that if there was a request for a surgical appointment for cataract removal, he expected the Social Services Director to arrange the appointment and transportation. These interviews and records showed that the facility did not ensure the resident received the ordered vision services in accordance with its own Vision Services Policy.
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