Failure to Timely Follow Up on Insurance Authorization for MBSS
Summary
The facility failed to follow up on insurance authorization for a modified barium swallow study (MBSS) in a timely manner for a resident, leading to a delay in service. The resident, who had multiple diagnoses including hemiplegia, COPD, dysphagia, and severe protein-calorie malnutrition, was admitted with a g-tube for feeding. Despite a physician's order for an MBSS, the facility did not ensure the authorization process was completed promptly, causing the resident to become angry and refuse meals. The resident's appointment for the MBSS was initially scheduled, but due to miscommunication and errors in transportation arrangements, the appointment was missed. The facility's business office assistant (BOA) faced difficulties in obtaining the necessary authorization from the insurance company, experiencing a runaround between the insurance company and the medical group. Despite multiple follow-up attempts, the authorization process was delayed, and the resident was not informed of the status in a timely manner. The resident expressed frustration and anger due to the delay in receiving the MBSS, which was necessary for evaluating the removal of the g-tube. The resident's refusal to eat the provided puree diet and the ongoing issues with the authorization process contributed to the resident's deteriorating mental state and increased agitation. The facility's failure to follow its own policy and procedures for timely follow-up on authorizations led to a significant delay in the resident's care and exacerbated the resident's distress.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple cardiopulmonary conditions reported increased fatigue and shortness of breath, leading the physician to order labs and a chest x-ray instead of hospital transfer. The x-ray showed linear opacities, pulmonary congestion, and an elevated hemidiaphragm, with a radiology recommendation for a follow-up HRCT lung scan. Documentation showed the physician and family were informed of the x-ray results, but the DON later confirmed there was no evidence that the HRCT was ordered or scheduled, and the physician stated he did not believe the recommended HRCT was necessary. The family member reported not being informed of the CT recommendation, and surveyors cited the facility for failing to ensure timely follow-up of the recommended radiologic study.
A resident with multiple chronic conditions had a stat chest x-ray ordered due to abnormal lung sounds, but the x-ray was delayed because the lab service could not initially locate the order. The x-ray was not completed until the next day, despite facility policy requiring timely diagnostic services, as confirmed by the DON.
A resident with a history of constipation and other medical conditions did not receive a KUB x-ray as ordered by a physician, despite experiencing abdominal pain and lack of bowel movement for several days. The facility's medical records lacked documentation of the x-ray or any rationale for its omission, as confirmed by the DON.
Failure to Act on Recommended Follow-Up HRCT After Abnormal Chest X-Ray
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a recommended radiologic follow-up study was scheduled and addressed in a timely manner for one resident who experienced a change in condition. The resident, admitted with multiple significant diagnoses including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss, complained of increased fatigue while resting in bed. The family requested hospital transfer, but nursing staff explained that the resident could be worked up at the facility, and the family agreed. The physician was notified and ordered a CBC, CMP, urinalysis, urine culture, and a chest x-ray for complaints of shortness of breath. The chest x-ray was completed and the results, dated 09/15/25, showed suboptimal evaluation due to rotation, linear opacities in the left lower zone possibly representing fibro-atelectatic changes, prominence of both pulmonary hila with attenuation of broncho-vascular markings representing congestion, and elevation of the left dome of the diaphragm. The radiology report recommended a follow-up high-resolution CT (HRCT) lung scan. A progress note the following day documented the chest x-ray findings and indicated that the resident’s family and physician were aware of the results. However, during interview, the DON stated she did not recall speaking with the physician about the HRCT recommendation and verified there was no evidence in the record that the HRCT lung scan had been ordered or scheduled. The physician, when interviewed, did not remember what had occurred with this resident, stated that upon re-review of the chest x-ray he did not see anything acute that needed to be addressed, and acknowledged that the HRCT was a recommendation but did not believe it was necessary at that time. The resident’s family member reported not being aware of the recommendation for a CT scan of the lungs. The surveyors determined that the facility failed to ensure that the recommended radiologic follow-up study was acted upon in a timely manner for this resident, resulting in the cited deficiency under the complaint investigation.
Delay in Stat Chest X-ray for Resident
Penalty
Summary
The facility failed to provide laboratory services in a timely manner for one resident who was admitted with multiple diagnoses, including peripheral vascular disease, major depressive disorder, chronic kidney disease, and dry eye syndrome. A physician ordered a stat chest x-ray for this resident due to rales in the left lower lobe of the lungs. However, a review of the medical record and staff interviews revealed that the x-ray order was not promptly processed; the lab service was initially unable to locate the order, and the x-ray was not completed until the following day. The facility's policy required timely provision of lab and diagnostic services, but this was not met in this instance, as confirmed by the Director of Nursing.
Failure to Provide Timely Radiology Services
Penalty
Summary
The facility failed to provide timely radiology services as per the physician's order for a resident experiencing constipation. Resident #107, who had a medical history including a humerus fracture, major depressive disorder, and age-related osteoporosis, was admitted with intact cognition and required moderate assistance for transfers. The resident's last recorded bowel movement was on 07/04/24, and by 07/08/24, the resident complained of lower abdominal pain and had not had a bowel movement in five days. The physician was notified and ordered a KUB x-ray on 07/09/24 to assess the situation. Despite the physician's order, the medical record for Resident #107 did not include documentation of the KUB x-ray being completed or any results from such an x-ray. An interview with the resident on 07/08/24 confirmed the absence of a bowel movement for six days, despite receiving medications to promote bowel movements, and the resident reported stomach cramping. The Director of Nursing confirmed on 07/15/24 that the KUB x-ray was not completed and there was no documentation explaining the rationale for this omission.
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