Delayed Radiology Services Lead to Resident's Hospitalization
Summary
The facility failed to provide timely radiology services for a resident who experienced an unwitnessed fall, resulting in a significant delay in diagnosis and treatment. The resident, who had a history of traumatic brain injury, hypertension, and cognitive deficits, fell in the early hours and was found on the floor by staff. Despite the physician ordering a STAT x-ray for the resident's hips due to pain, the order was initially placed as routine, leading to a delay in the x-ray being performed. The resident continued to experience increasing pain throughout the day, and the x-ray results were not obtained in a timely manner. The nursing staff failed to follow up adequately on the x-ray order and did not escalate the resident's care despite her worsening condition. The resident's family expressed concern about the delay in receiving x-ray results and the resident's increasing pain, which eventually led to the resident being sent to the hospital, where a hip fracture was diagnosed. Interviews with staff revealed a lack of training and understanding regarding the urgency of STAT x-ray orders and pain management. The facility did not have a policy in place for x-ray services, and there was a failure to document and communicate effectively among the nursing staff and with the physician. This lack of timely intervention and follow-up placed the resident at risk for increased pain and delayed treatment.
Removal Plan
- Medical Director has been notified of the Immediate Jeopardy by the Administrator. QAPI was conducted with the medical director.
- Administrator/Designee initiated in-service on abuse and neglect.
- Regional Nurse to educate DON regarding assessing residents for pain after an incident, ordering STAT X-ray, completion, and follow-up of X-ray. Education includes obtaining order for X-ray, entering order in EHR/Matrix, sending the resident to the ER for evaluation if in-house X-ray cannot be obtained timely.
- DON/Designee initiated in-services with charge nurses/agency nurses on how to order a STAT X-ray, timely follow-up on X-rays related to X-ray completion and results which should be obtained within four hours when related to injury/pain, if longer than four hours resident(s) need to be transported to emergency room per physician's order.
- In-service charge nurses/agency nurses on notification to the DON/designee after hours and on weekends related to resident falls and results of pending X-rays initiated.
- Audit was completed on X-rays ordered in the last 30 days.
- Charge nurses, agency nurse/aides, and certified staff not working during the in-services on X-rays, will be in-service prior to their next scheduled shift. Staff will not be allowed to work until in-service is complete. Newly hired staff will receive the in-services during their orientation period.
- The weekend supervisor was in-service monitoring the Facility Activity Report and follow-up on orders i.e, X-ray, and residents with pain.
- Monitoring will occur during the clinical morning meeting Monday through Friday; weekend supervisor will review the Facility Activity Report for resident falls and new orders. If concerns are noted by the weekend supervisor the DON will be contacted. The DON will be responsible and monitor residents' post fall with major injury for timely completion of X-ray and results.
- Facility charge nurses and agency nurses will be given a competency-based quiz on following physician orders.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple comorbidities, including venous insufficiency and CHF, had a right lower extremity duplex ordered, but the contracted radiology provider did not perform the exam within the 24-hour timeframe required by contract and did not communicate the delay to the facility. The imaging was completed several days after the order, and the results were not read or transmitted until days after the exam, despite the provider’s usual 6–8 hour turnaround. Facility leadership confirmed they did not receive results until days later and only contacted the radiology company after the family asked about the test, and there was no documentation of communication between the facility and the provider regarding the delays.
The facility did not maintain or produce a written agreement for radiology and other diagnostic services that were not provided directly on-site. During surveyor review of facility documents and policies, no contract or agreement could be found to verify how these diagnostic services were arranged. In an interview, the Administrator reported being unable to locate the radiology services contract, noting that important document binders had been relocated after a recent facility-wide evacuation. Consequently, the facility could not demonstrate that it had a formal, documented arrangement to ensure timely access to required radiology and diagnostic services for residents.
A resident with an acute cough and a history of chronic bronchitis and pneumonia had a STAT chest x-ray ordered by an NP, who entered the order into the computer and informed nursing staff. The DON reported that the facility’s protocol requires nursing staff to call the x-ray provider for STAT orders, which are typically completed within hours with same-day results, but no documentation or evidence of the x-ray being performed or results received could be found. This failure to carry out the STAT radiology order did not follow the facility’s policy requiring timely provision or procurement of ordered diagnostic services.
A resident fell backwards from a wheelchair, developed lower back pain, and had a lumbar X-ray ordered by an NP. When the X-ray tech attempted the study, it could not be completed due to weight concerns, and the tech did not return with additional support as stated. Staff did not notify the physician, NPs, or the resident’s POA that the ordered X-ray was not completed, and there was no documentation of such notification. The resident’s back pain worsened and the resident was later sent to a hospital, where a thoracic vertebral fracture was diagnosed, revealing that the ordered lumbar X-ray had never been performed despite facility policy requiring appropriate diagnostic services.
A resident with COPD, heart failure, bronchitis, emphysema, and a solitary pulmonary nodule experienced shortness of breath and a physician gave a verbal order to an LPN for a chest x-ray. Due to miscommunication, the LPN did not enter the order or notify the mobile radiology service that day. The x-ray order was entered the next morning as STAT, but the exam was still not completed before the resident was later sent to the hospital for vomiting and shortness of breath, contrary to facility policy requiring timely radiology services when ordered.
A resident with a history of goiter had a chest X-ray that showed worsening mediastinal findings and specifically recommended a CT scan, but staff did not obtain a CT in a timely manner. The CT was ordered weeks after the initial recommendation, then the scheduled test was discontinued when the imaging provider would not accept the resident on a stretcher, and no alternative arrangements were documented. Subsequent hospital imaging again recommended outpatient chest CT correlation, yet the CT was not ordered or completed until the resident was later sent back to the hospital. The Regional Director of Clinical Operations confirmed staff failed to follow up and obtain the CT over this extended period.
Failure to Ensure Timely Diagnostic Imaging and Results
Penalty
Summary
The deficiency involves the facility’s failure to obtain and/or ensure timely diagnostic imaging and results for a resident with multiple complex medical conditions. The resident was admitted with diagnoses including hydronephrosis, hypertension, type 2 diabetes mellitus, diabetic foot ulcer, venous insufficiency, and congestive heart failure. An order was placed on February 6, 2026, for a right duplex venous scan related to venous insufficiency, and the order indicated the imaging was sent that same day. The radiology company reported that the exam was not actually performed until February 9, 2026, three days after the order, despite a contract requirement that services be provided within 24 business hours or a time be scheduled with notification to the facility if that timeframe could not be met. The radiology company further stated that results are usually available within six to eight hours after imaging, but in this case the exam was not read by a radiologist and the results were not sent to the facility until February 13, 2026. The DON confirmed the facility did not receive the diagnostic imaging results until February 13, 2026, and that she only contacted the radiology company after the resident’s family inquired about the results during a care plan meeting that same day. The radiology company liaison and territory manager acknowledged the delays in both performing the duplex and in resulting the exam, and indicated there was no communication with the facility about these delays, contrary to the contractual obligation to promptly notify the facility if the 24-hour service time could not be met. The facility did not have documentation showing any communication with the radiology company regarding the delayed exam or delayed receipt of results.
Failure to Maintain Written Agreement for Radiology and Diagnostic Services
Penalty
Summary
The facility failed to maintain and provide a written agreement for radiology and other diagnostic services when such services were not provided directly by the facility. During document and policy review, surveyors were unable to obtain any written agreement or contract verifying how radiology and other diagnostic services were arranged. An interview with the Administrator revealed that she could not locate the requested radiology services contract at the time of the survey. She explained that, following a recent facility-wide evacuation, binders containing important documents had been relocated, and the specific agreement for radiology and diagnostic services could not be produced. As a result, the facility was unable to provide documentation demonstrating that required diagnostic services were available in a timely manner to meet resident needs. No specific residents or their medical conditions were identified in the report.
Failure to Obtain Ordered STAT Chest X-Ray
Penalty
Summary
The facility failed to obtain a STAT chest x-ray as ordered for one resident, resulting in noncompliance with its policy to provide or obtain timely diagnostic services. A nurse practitioner documented on 2/5/26 that the resident had an acute cough and, due to a history of chronic bronchitis and pneumonia, ordered a STAT chest x-ray, entering the order into the computer and verbally informing the nurse. The nurse practitioner later stated she had not seen any x-ray results and did not know if the x-ray had been completed. The DON explained that the facility’s process for a STAT x-ray requires the nurse to call the x-ray provider, who typically performs the x-ray within four hours with same-day results, but she was unable to find any evidence that the x-ray had been performed. The facility’s Laboratory and Diagnostic Services and Reporting Policy requires that laboratory and diagnostic services, including radiology, be provided or obtained when ordered and that nurses carry out such orders per facility protocol.
Failure to Complete Ordered Lumbar X-Ray and Notify Providers After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered radiology services were completed or alternative arrangements made after a resident sustained a fall with resulting back pain. The resident fell backwards from a wheelchair onto the floor, landing on his back, and subsequently complained of lower back pain. A nurse practitioner ordered a lumbar X-ray to be completed in the facility, with a physician order specifying 2–3 views of the lower lumbar area related to trauma and pain. When the X-ray technician arrived, the study could not be completed due to weight concerns and the technician stated that an additional tech and a special board would be needed to hold the resident. The X-ray staff did not return to complete the ordered study, and the lumbar X-ray was never performed in the facility. The resident continued to complain of back pain and was later transferred to a local hospital due to worsening pain, where he was diagnosed with a thoracic vertebral fracture. Facility progress notes for the day the X-ray attempt failed contained no documentation that the physician, nurse practitioners, or the resident’s POA were notified that the ordered X-ray was not completed. An LPN confirmed she did not notify the POA or either nurse practitioner that the X-ray was not done. The POA and both nurse practitioners reported they were not informed until the following day, shortly before or on the day the resident was sent to the hospital, that the X-ray had not been completed as ordered. This failure occurred despite a facility policy stating it will provide appropriate diagnostic services, including radiology, in accordance with state and federal guidelines.
Failure to Obtain Ordered STAT Chest X-Ray for Resident with Respiratory Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to obtain a chest x-ray as ordered for a resident with multiple serious pulmonary and cardiac diagnoses, including COPD, heart failure, bronchitis, emphysema, and a solitary pulmonary nodule. The resident was admitted with these conditions and later experienced a change in condition characterized by shortness of breath. On the morning of 1/24/26, a physician (MD 3) gave a verbal order to a licensed nurse (LN 2) for a chest x-ray. However, this order was not entered into the medical record on that date, and the mobile radiology service was not notified that day. As a result, there was no chest x-ray order documented on 1/24/26 in the facility’s order summary report. On 1/25/26, the chest x-ray order was finally entered into the system as a STAT order, which the Assistant Director of Nursing (ADON) stated should have been completed within six hours. Despite this, the mobile radiology service was not contacted until the morning of 1/25/26, and the chest x-ray was still not completed by the time the resident was transferred to an acute care hospital at 10:20 p.m. that evening for multiple episodes of vomiting with shortness of breath. The ADON confirmed that the chest x-ray should have been completed the same day it was originally ordered and that the facility’s policy requires obtaining radiology services when ordered. The failure to timely enter the order and notify the radiology provider resulted in the ordered chest x-ray not being performed prior to the resident’s transfer.
Failure to Obtain Timely CT Imaging After Abnormal Chest X-Ray
Penalty
Summary
Facility staff failed to obtain a timely diagnostic CT scan as recommended and ordered for a resident with a history of goiter. The resident was admitted in 2024 with diagnoses including goiter and later had a chest X-ray on 3/3/25 to rule out pneumonia. The X-ray report noted nonspecific superior mediastinal widening with overall findings worse compared to a prior study from 4/22/2024 and specifically recommended a CT scan. Despite this recommendation, a physician order for the CT scan was not placed until 3/28/25. That order was updated on 4/3/25 to include a scheduled CT date of 4/8/25. On 4/7/25, the CT scan order was discontinued because the imaging provider would not take the resident on a stretcher, and no alternative arrangements were documented in the record at that time. The resident was hospitalized from 4/15 to 4/18/25, and the hospital discharge summary again referenced imaging that showed moderate left paratracheal soft tissue density deviating the trachea to the right, compatible with probable substernal thyroid, and recommended correlation with a chest CT as an outpatient. The chest CT was not ordered or obtained until the resident was sent to the hospital on 6/9/25. The Regional Director of Clinical Operations confirmed that facility staff failed to follow up and obtain the CT scan from 3/3/25 until 6/9/25.
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