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 provide hearing services for a resident with documented hearing loss. The resident used a journal to communicate, staff reportedly spoke loudly to the resident, and the resident said the facility had assessed hearing but had not followed up. Records showed moderate difficulty hearing, a care plan for poor hearing, and an audiology eval finding moderately severe to profound sensorineural hearing loss in both ears with a recommendation for hearing aids and medical clearance.
A resident reported requesting a hearing screening but still waiting for a hearing test, and the medical record lacked documentation of any hearing appointment or consultation. The DON later acknowledged the facility failed to submit the required audiology paperwork to the outside consultant, so the resident did not receive the hearing screen.
A resident with visual impairment reported that bedside glasses did not work and that a requested ophthalmology visit had not occurred, while documentation showed earlier notes of adequate vision followed by entries indicating vision loss, need for assistance, and a provider recommendation for ophthalmology follow-up. Staff described a process for arranging ophthalmology services and acknowledged the resident’s partial blindness and non-functioning glasses, and an NP documented the resident’s complaints of difficulty seeing and dry eyes, noting attempts to schedule an ophthalmology appointment complicated by insurance questions. Despite these documented concerns and awareness by nursing, NP, and DON, there was no evidence that an ophthalmology evaluation was obtained or that the resident’s vision impairment was appropriately assessed and treated.
A resident reported being unable to see without glasses and that their glasses were broken, and an NP documented the need for glasses. Despite ongoing notes about frequent falls, dizziness, and blurred vision, and documentation that the resident’s baseline vision was poor and that no glasses were at the bedside, there was no record that vision services were arranged or that glasses were obtained. The resident later confirmed that the glasses had not been replaced and that staff had only stated they would address it, while an RN on the unit was unaware of the glasses issue. The NP stated she had informed nursing staff but could not recall whom, and the Medical Director agreed that the glasses issue and the resident’s complaints of poor vision should have been followed up on.
A resident with documented bilateral hearing loss and moderate hearing difficulty, as assessed in the MDS, did not receive an audiology consultation or hearing aids since admission. The facility's only intervention was the use of a whiteboard for communication, and the Clinical Service Director confirmed that no audiology referral had been made.
A resident who had been assigned readers by an eye doctor did not have glasses after returning from a hospital visit, despite repeatedly requesting assistance from staff. Observations confirmed the absence of glasses, and the DON acknowledged the issue.
A resident with documented impaired vision and a need for corrective lenses was observed struggling to eat without glasses and confirmed difficulty seeing. Medical records showed a missed follow-up eye exam, and the DON could not verify if the resident received the required care, with an appointment only scheduled after surveyor intervention.
A resident with significant hearing and vision impairment was not assisted in obtaining necessary hearing aid repairs, despite staff awareness of the issue. The hearing aid remained nonfunctional and unused, and staff interviews revealed a lack of communication and follow-through to address the resident's needs.
A resident experienced decreased vision and was scheduled for a follow-up with an eye specialist, but there was no documentation that the appointment occurred. Interviews revealed that Medical Records staff, responsible for scheduling and transportation, were unaware of the appointment, resulting in the missed follow-up.
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