Failure to File Diagnostic Reports in Resident's Medical Record
Summary
The facility failed to file signed and dated reports of radiological and other diagnostic services in the resident's clinical record, specifically for one resident. This resident, who had diagnoses including dementia, hypertension, acute kidney failure, and anxiety disorder, was admitted and readmitted to the facility. An ultrasound was performed on the resident's right lower extremity, revealing a deep vein thrombosis, but the report was not filed in the medical record. The Director of Nursing (DON) acknowledged the absence of a policy for urgent ultrasounds and noted that the nursing staff lacked critical thinking skills, which contributed to the oversight. Additionally, the resident experienced right hip pain following a fall, prompting an order for a STAT x-ray. The x-ray revealed an acute femoral neck fracture, but the results were not filed in the resident's medical record, nor were they signed or dated. The DON explained the process for handling x-ray orders, which involved contacting a mobile x-ray company and notifying the MD once results were available. However, the process was not secure, and the x-ray results were not properly documented or communicated in a timely manner. The DON admitted that the facility's procedures for handling STAT orders and filing diagnostic reports were inadequate. The x-ray company was contacted, and the x-ray was performed several hours later, with results faxed to the facility. Despite this, the results were not entered into the resident's medical record, and the resident was not sent to the hospital until the following day. The DON recognized the need for improvement in the facility's processes to ensure timely and accurate documentation of diagnostic services.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with paroxysmal atrial fibrillation, repeated falls, and unspecified tremor had a head CT ordered for increased confusion and a high INR, and was transported to the hospital for the test. Surveyors found the CT results were not filed in the medical record, and the DON stated she had to request the report from the hospital because it was missing from the chart.
A resident with multiple complex diagnoses had a STAT KUB x-ray ordered and performed due to abdominal symptoms, but the signed and dated x-ray report was not filed in the clinical record. Staff interviews revealed inconsistencies in the process for handling and filing diagnostic results, resulting in the required documentation being unavailable in the resident's chart.
Missing Diagnostic and Lab Results in Resident Records: The facility failed to file lab and diagnostic reports in the clinical records for two residents. One resident with cancer-related diagnoses had a CBC/CMP result missing from the EMR, and another resident with DM, CHF, CAD, and other chronic conditions had multiple lab results not uploaded to the EMR despite active orders and care plan directions to monitor labs and diagnostic work.
A resident who experienced increased heart rate and low-grade fever had a stat EKG ordered by a nurse practitioner. Although an LPN reported that the EKG was performed, the signed and dated EKG report was not filed in the resident's medical record, as confirmed by a review of the electronic record and staff interview.
A resident with a history of traumatic subdural hemorrhage and paraplegia reported genital pain, leading to a physician's order for an ultrasound. The ultrasound was performed, but the results were not filed in the clinical record, reviewed by staff, or reported to the attending physician as required by facility policy. Staff were unaware of the missing results until prompted by a surveyor.
A resident receiving antibiotics for pneumonia did not have a signed and dated chest x-ray report filed in their clinical record, despite staff confirming that such a report should have been present to support the diagnosis and treatment.
Missing CT Report in Resident Record
Penalty
Summary
Keep signed and dated reports of x-rays and other diagnostic services in the resident's record was cited after surveyors found that one of 25 sampled residents did not have radiologic reports filed in the clinical record. Resident 14 was admitted with diagnoses including paroxysmal atrial fibrillation, repeated falls, and unspecified tremor. The resident's record showed that on 8/18/25 a nurse documented that the provider ordered a head CT due to increased confusion and a high INR, and that the resident was transported to and from the hospital for the appointment. However, the head CT results could not be located in the medical record. During interview, the DON stated she had to request the head CT results from the hospital because they were not in the record, and stated that radiology results should be uploaded into the medical record under the miscellaneous tab.
Failure to File Signed and Dated Diagnostic Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.
Missing Diagnostic and Lab Results in Resident Records
Penalty
Summary
The facility failed to file signed and dated reports of x-rays and other diagnostic services in the clinical records for 2 of 8 residents reviewed. Resident #3, an older male with diagnoses including cerebral infarction, dysphagia, acute myeloblastic leukemia not having achieved remission, multiple myeloma, and immunodeficiency, had an active order for CBC and CMP related to multiple myeloma dated 09/14/2025, but the lab result was not uploaded to his electronic medical record when reviewed on 10/08/2025. His care plan included chemotherapy treatment and education on the importance of routine laboratory monitoring. Resident #4, an older male with diagnoses including muscle weakness, diabetes mellitus, hyperlipidemia, hypertension, atherosclerotic heart disease, atrial fibrillation, and heart failure, had multiple active lab orders related to diabetes, a sacral ulcer, and CHF. Record review on 10/07/2025 showed that lab results ordered on 02/08/2025, 03/16/2025, 03/18/2025, and 04/11/2025 were not uploaded to his electronic medical record. His care plan included monitoring lab and diagnostic work as ordered, monitoring cholesterol levels, and fasting serum blood sugar as ordered by the doctor.
Failure to File Signed and Dated EKG Report in Medical Record
Penalty
Summary
The facility failed to file a signed and dated EKG report in the medical record for one resident. The resident had experienced an increased heart rate and low-grade fever, prompting a nurse to consult with a nurse practitioner, who ordered a stat EKG, chest x-ray, and urinalysis. Although the EKG was reportedly performed later that day, a review of the resident's medical record did not contain any evidence of the EKG being completed or filed, as confirmed by both the electronic results tab and the miscellaneous section of the record. During an interview, the LPN explained that the EKG should have been downloaded into the medical record but was not, resulting in the absence of the required documentation.
Failure to Maintain and Communicate Diagnostic Test Results
Penalty
Summary
The facility failed to ensure that the results of a diagnostic ultrasound were maintained in the clinical record, reviewed by staff, and reported to the attending physician for one resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and paraplegia, reported genital pain to staff. A physician's order was placed for an ultrasound, which was performed on the same day. However, the results of the ultrasound were not included in the resident's clinical record, nor were they reviewed or communicated to the attending physician as required by facility policy. Interviews with staff revealed that the unit manager was unaware of the missing results until prompted by the surveyor and had not reviewed or reported the findings to the physician. The DON confirmed that results should be reviewed and reported the day they are received, but was not aware that this had not occurred for this resident. The facility's policy requires documentation of when, how, and to whom diagnostic information is provided, but this process was not followed in this instance.
Missing Signed and Dated Chest X-ray Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated chest x-ray report in the clinical record of a resident who was being treated for pneumonia. The resident, who had a history of chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, was admitted with these diagnoses and subsequently received two different antibiotics for infectious pneumonitis and pneumonia. Documentation in the medical record included orders for Amoxicillin-Potassium Clavulanate and Doxycycline, as well as nursing notes referencing the treatment for pneumonia. Despite the clinical indications and treatment for pneumonia, a review of the resident's medical record revealed that the chest x-ray report, which would have confirmed the diagnosis, was not present in the file. Interviews with nursing staff and the regional nurse consultant confirmed that a chest x-ray would have been ordered to support the diagnosis, but the report was not located in the record at the time of review. The absence of a signed and dated radiological report in the resident's clinical record constituted the deficiency.
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