Failure to Notify Physician of Abnormal Lab Results
Summary
The facility failed to notify the physician or nurse practitioner of a sacral wound culture result indicating a high amount of bacteria, specifically greater than 100,000 pseudomonas aeruginosa, for a resident with a stage three sacral pressure ulcer. This oversight affected one of the three residents reviewed for notification of abnormal lab results. As a result, the resident did not receive any antibiotic treatments and was hospitalized two weeks later with a diagnosis of sacral osteomyelitis. The resident was admitted with multiple diagnoses, including sepsis, a stage three sacral pressure ulcer, quadriplegia, anemia, muscle wasting, and adult failure to thrive. A wound assessment documented signs of infection, and a wound culture was ordered. However, the results were not communicated to the appropriate medical personnel. Interviews with staff revealed a lack of clarity and follow-up regarding the culture results, with several staff members, including the wound care coordinator and infectious disease nurse practitioner, unaware of the results. The facility's policy required that test results be reported to the ordering physician to ensure prompt and appropriate action. Despite this, the culture results were not communicated, and no new antibiotic treatments were documented for the resident after the culture was reported. The resident's condition worsened, with the pressure ulcer progressing to stage four, and the resident was eventually diagnosed with sacral osteomyelitis, highlighting the failure to act on the abnormal lab results.
Penalty
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Below are regulatory guidelines relevant to this citation:
An EKG ordered for a resident taking Abilify was not completed as ordered. The resident had heart disease and moderately impaired cognition, and the ADON confirmed during record review that the EKG should have been done but there was no documented reason for the missed test.
A resident with pleural effusion, COPD, HTN, HF, and lower-leg cellulitis had physician-ordered bilateral venous and arterial doppler studies for the lower legs, but the tests were not scheduled and no results were available in the record. The ADON verified the missed scheduling and stated nurses are expected to review written orders and arrange the ordered testing.
A resident with interstitial pulmonary disease, Parkinson's disease, and dementia developed vomiting and generalized weakness, and the physician ordered a stat chest X-ray. The DON confirmed there was no documentation that the physician was notified of the result, and the physician stated he was not notified even though the X-ray was later reviewed as normal on the day of the resident's transfer to the hospital. The facility policy required the attending physician to be promptly notified of diagnostic test results.
Delayed Notification of MRI Results: A resident with impaired cognition and a history of falls sustained a fall with severe right shoulder pain and was sent to a GACH, where x-ray findings were negative. The resident later had an MRI that showed nondisplaced humerus and scapular fractures, but the results were emailed to the ADON and not relayed to the ordering MD until the next day because the ADON had already left and no one else could access the email. Facility notes did not document follow-up on the imaging report, and staff confirmed the resident continued to have pain and limited RUE function.
A resident with cancer involving the kidney and bone, a history of falls, low back pain, and a prior femur fracture had a STAT bilateral hip X-ray ordered after a change in condition. RN contacted the DDP, but the test was delayed until the next morning and the physician was not notified of the delay. The ADON confirmed STAT orders were expected within 4 hours and that there was no documentation of physician notification.
A resident with multiple comorbidities and limited mobility fell from bed and had an x-ray that showed a nondisplaced distal femur fracture. The LPN received the result but did not call the on-call MD after hours, instead sending the image to the NP without confirmation or response. The result was not handed off to the next shift, the resident remained in pain, and the NP did not learn of the fracture until the next day, when the resident was sent to the hospital.
EKG Ordered for Abilify Was Not Completed
Penalty
Summary
The facility failed to ensure that an EKG ordered by a physician for one resident was completed. The resident was admitted with diagnoses including heart disease and unspecified psychosis, and the MDS showed moderately impaired cognition with partial to substantial assistance needed for several activities of daily living. A physician order dated 6/20/2026 directed an EKG every day shift every 12 months starting on the 22nd for one day for the use of Abilify per pharmacy recommendation. During a concurrent interview and record review, the ADON reviewed the resident’s physician orders and nursing progress notes and stated that the EKG was not done as ordered. The ADON stated the EKG should have been completed on 6/22/2026 and that there was no documented evidence explaining why it was not done. The ADON also stated the EKG was important because it was a pharmacy recommendation related to the resident’s use of Abilify.
Failure to Schedule Ordered Diagnostic Testing
Penalty
Summary
The facility failed to schedule ordered diagnostic tests for one resident reviewed for diagnostic testing. Resident #16 was admitted with diagnoses including pleural effusion, COPD, high blood pressure, heart failure, and cellulitis of the lower leg, and the admission MDS indicated moderately impaired cognition. Physician orders dated 07/01/26 included bilateral venous doppler and bilateral arterial doppler studies for the lower legs, but the resident’s record contained no results from those ordered tests. During interview on 07/16/26 at 10:53 A.M., the ADON verified that the bilateral venous doppler and bilateral arterial doppler had not been scheduled by the facility and stated that nurses are expected to review written physician orders and schedule the ordered testing.
Failure to Notify Physician of Chest X-Ray Result
Penalty
Summary
The facility failed to notify the physician of the result of a stat chest X-ray ordered for one resident after the resident had an episode of vomiting and generalized weakness. The resident had diagnoses that included interstitial pulmonary disease, Parkinson's disease, and unspecified dementia, and was under the care of Physician 1. After the resident was noted with a mild nonproductive cough and later developed vomiting and generalized weakness, Physician 1 ordered a stat chest X-ray. During record review, the Director of Nursing confirmed there was no documentation in the resident's electronic medical record showing that Physician 1 was notified of the chest X-ray result. Physician 1 stated he was not notified of the result and said the chest X-ray was normal when he later reviewed it on the day the resident was transferred to the hospital for further evaluation. The facility policy titled Test Results stated that the attending physician will be notified of diagnostic test results and that if results are provided to the facility, the attending physician shall be promptly notified.
Delayed Notification of MRI Results
Penalty
Summary
Facility staff failed to promptly review MRI results and immediately notify the ordering practitioner for a resident who had fallen and continued to have right shoulder pain. The resident was admitted with diagnoses including abnormalities of gait and mobility, unspecified psychosis, and a history of falling. The resident’s MDS showed moderately impaired cognition and need for partial/moderate assistance with several ADLs. After an unwitnessed fall, the resident complained of 10/10 right shoulder pain and was sent to a GACH by 911. The hospital H&P noted a ground level fall with resolving right shoulder and arm pain and no fracture on x-ray. Because the resident continued to have pain and guarded the right arm, therapy staff awaited MRI results before changing the therapy plan. The resident went to the MRI appointment with a facility staff member, and the imaging center later told staff the full report would be available in three days. The MRI report, dated 5/7/2026, showed a nondisplaced proximal humerus fracture involving the surgical neck, greater tuberosity, and lesser tuberosity, as well as a nondisplaced scapular fracture extending through the glenoid, scapular neck, and scapular body. Facility progress notes from 5/7/2026 through 5/10/2026 did not document follow-up on the imaging report. The MRI results were emailed to the ADON’s work email at 1:34 PM on 5/11/2026, but the ordering physician was not notified until 10:26 AM on 5/12/2026. The ADON stated the results were not reported sooner because the email arrived after the ADON had left the facility, and no one else had access to that email. The ADON stated critical test results must be relayed to the physician immediately. Interviews with the DON and nursing staff confirmed the resident continued to have pain and reduced right upper extremity function after the fall, and the DON stated nursing should follow up on test results and that delays in care can occur.
Delay in STAT bilateral hip X-ray and failure to notify physician
Penalty
Summary
The facility failed to provide radiology services to meet the needs of one resident when a bilateral hip X-ray was ordered STAT and the physician was not notified of the delay in completing the test. The resident was admitted with diagnoses including malignant neoplasm of the right kidney with secondary malignant neoplasm of bone, history of falling, low back pain, and a pathological fracture of the left femur. The resident’s MDS indicated intact cognition and need for moderate to maximal physical assistance with ADLs. The physician ordered a bilateral hip X-ray STAT on 5/11/2026 at 6:00 p.m. RN 1 stated she contacted the designated diagnostic provider, which said it could not arrive until early the next morning, and she did not notify the physician of the delay. The ADON stated STAT orders were expected within four hours, that the X-ray was completed at 12:25 a.m. on 5/12/2026, and that there was no documentation that the physician was informed of the delay. The DON stated the facility did not follow the timeframe for the STAT order.
Delayed Notification of Femur Fracture Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of a radiology result that showed a right distal femur fracture for a resident who had fallen from bed and reported significant pain. The resident had multiple diagnoses including heart failure, depression, pressure ulcers, bone infection, muscle weakness and paralysis following a stroke, deep vein thrombosis, and an unspecified femur fracture. She was cognitively impaired, used a wheelchair, and required total assistance for transfers and bed mobility. After the resident fell while awaiting wound care, an x-ray of the right knee was ordered. The radiology report identified a mildly comminuted, nondisplaced fracture across the distal femur with soft tissue swelling and effusion. The radiology provider reported that the fracture result was communicated to LVN K by phone at 9:39 PM, but LVN K did not call the on-call physician and instead sent a picture of the result to the NP. LVN K stated she did not speak to the NP and no orders were received before she left at 10 PM. The resident remained in pain, with pain assessments documented at 4/10, 3/10, and 5/10 over the following hours. Multiple staff interviews showed the fracture was not communicated through the facility's approved notification process and was not handed off to the next shift. The night nurse stated she was not told about the fall, pending radiology results, or fracture, and therefore did not assess the resident or notify the on-call physician. The NP stated she was not aware of the fracture until the next day, and the resident was then sent to the hospital. Facility policy required the attending physician to be promptly notified of diagnostic test results, required the charge nurse or DON to notify the physician, and required immediate notification for suspected fractures and after-hours critical findings.
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