Delayed Physician Notification of Abnormal X-ray Results Following Resident Fractures
Summary
The facility failed to promptly notify the ordering physician of abnormal x-ray results for a resident, resulting in significant delays in medical intervention. On two separate occasions, the resident sustained fractures to the lower extremities after incidents involving transfers from a shower chair to the bed. In both cases, x-rays were ordered and results indicating fractures were received by the facility, but there was a delay in notifying the physician and in sending the resident to the hospital. For the first incident, the x-ray result showing a left tibia fracture was received, but the resident was not sent to the hospital until five days later. For the second incident, the x-ray result showing a right tibia fracture was received, but the resident was not sent to the hospital until the following day. Interviews and record reviews revealed that nursing staff either did not notify the nurse practitioner (NP) immediately or failed to follow up when no response was received. In some cases, staff relied on text messages to communicate critical results and did not escalate the situation when the NP did not respond. Documentation was inconsistent regarding how and when the NP was notified, and there was confusion among staff about the appropriate steps to take when a physician could not be reached. The Director of Nursing (DON) and other staff members confirmed that there was a lack of clarity and follow-through in the notification process, and that the facility's policies for prompt physician notification were not followed. The resident involved had a history of multiple sclerosis, lack of coordination, and was dependent on staff for transfers and personal care. After each incident, the resident experienced pain and reported that the pain was not adequately managed until she was sent to the hospital. The facility's failure to promptly notify the physician and act on abnormal diagnostic results led to delays in appropriate medical treatment for the resident.
Removal Plan
- The DON, ADON D, and ADON E completed a change of condition assessment focusing on pain on each resident to determine if they are not at their baseline. Each resident was documented on the outcome of their assessment in their progress note in Point Click Care. For any residents that were found not to be at their baseline, their physician was notified and documented on. Any conditions noted after this immediate assessment, and it was found that the physician was not notified, a re-education of physician notification was completed.
- Either DON, ADON D, ADON E, or LVN CC will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- In-services were initiated by the Chief Nursing Officer. Any nurse not present or in-serviced will not be allowed to assume their duties until in-serviced. The ADM and human resources will ensure these team members are removed from the time clock and PCC access removed. This will be monitored until 100% complete or the team members are terminated. Ongoing in-service will be completed by the DON, ADON D, and ADON E until all staff, weekend, and PRN are completed.
- Post-test will be completed to evaluate team members' understanding of in-services covered. The passing score will be 80% - 100%.
- Licensed nurses were in-serviced on: Notifying physicians during a change of condition in a resident; Physician on-call schedule; Process on what to do if a physician cannot be reached; Comprehensive Pain Management Treatment Plan for each resident.
- The medical director was notified of the immediate jeopardy situation by the DON.
- The Ombudsmen was notified of this Immediate Jeopardy situation by the ADM.
- The Corporate Nurse immediately audited the 24-hour facility resident summary to determine if there were any changes of conditions focusing on pain that were noted, and the physician was notified. These findings were sent to the DON, ADON D, and ADON E for follow-up.
- The chief nursing officer reviewed the administrative nurse's follow-up to ensure follow-up happened and will do this daily.
- DON, ADON D, and ADON E will monitor daily residents' current electronic records for a change of condition utilizing the Point Click Care Clinical Dashboard, which includes resident's Change of Condition, 24 Hour Resident Report, Progress notes, Incidents & Accidents, Weights & Vitals, and Diagnostic reports on all residents daily.
- To ensure accuracy, DON, ADON D, and ADON E will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions. These rounds will be documented on the resident 24-hour report. The ADM will monitor this process daily.
- Interviews were conducted with nurses to verify understanding of on-call physician number access, notification process, change in condition identification, and escalation if unable to reach a provider.
- Record review of facility in-services titled Notifying Physicians During a Change of Condition, Physician On Call Schedule, and What to do if a Physician cannot be reached revealed all nursing staff had signed indicating education was completed by all nurses.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident experienced a witnessed fall from a wheelchair, striking the head and later developing swelling and bruising around one eye. Nursing staff notified the physician, and a PA subsequently evaluated the resident, noting headache and vision changes and ordering an orbital x-ray. The medical record shows no evidence that the ordered x-ray was ever completed or that results were obtained, even though the facility’s assessment states it will provide access to diagnostic x-ray services. The resident later had another fall and was sent to the hospital, where a head CT was performed, and the ADON later confirmed the orbital x-ray had not been done.
A resident’s x-ray results were reported to the facility but were not promptly communicated to the nurse practitioner. An LPN checked the EMR once during the night and saw the results as pending, did not recheck later in the shift, and did not notify the NP. An RN later documented that results were relayed and the NP ordered hospital transfer, but the NP reported they were not notified by staff and only became aware of the results upon independently reviewing the EMR. The DON stated nurses are expected to check for x-ray results at shift start and end and immediately notify the NP when results are available.
A resident with severely impaired cognition, mobility limitations, and multiple medical conditions fell onto a floor mat while returning from the bathroom, as reported by a cognitively impaired but decision-capable roommate who activated the call light. An RN Supervisor assessed the resident, who reported mild left wrist pain, and notified the physician, who issued a stat order for a left wrist x-ray and Tylenol for pain. The facility’s policy required stat orders to be completed within four to six hours, but surveyors found that the stat x-ray was not completed within this timeframe, resulting in a cited deficiency for failure to timely complete the ordered diagnostic test.
A resident with elevated liver enzymes had a physician order for a right upper quadrant ultrasound, but nursing staff did not complete the ordered test. Review of the medical record showed no ultrasound results, and the DON confirmed that the ordered diagnostic study was never carried out, resulting in a failure to follow the practitioner’s order for necessary testing.
A resident with a Stage 3 necrotic sacral pressure injury had a physician order for a sacrum/pelvis x-ray to evaluate for osteomyelitis, but the x-ray was never completed. An RN entered the order into the radiology provider’s portal, but the test was not done before the end of the shift, and there was no documented nursing follow-up to confirm completion or obtain and report results to the practitioner. The DON later learned from the radiology provider that the x-ray had been cancelled due to lack of a credentialed radiologist to read it, and the facility had not been notified of this cancellation, resulting in the ordered diagnostic test not being provided.
A resident with multiple respiratory conditions and impaired cognition had abnormal lab and chest x-ray results indicating a possible infection. Nursing staff failed to verify that these results were received by the physician or nurse practitioner, and there was no documentation of provider notification or follow-up. As a result, the resident did not receive timely medical intervention for the abnormal findings, and required notification procedures were not followed.
Failure to Complete Ordered Orbital X-Ray After Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an ordered orbital x-ray was completed for a resident following a fall with head impact. The facility’s Facility Assessment dated 11/1/25 states that the facility will employ or contract staff to provide clinical laboratory and diagnostic x-ray services. Nursing progress notes document that the resident had a witnessed fall in the hallway, during which the resident, who was wheeling himself in a wheelchair, scooted out of the chair and hit his head. The following day, nursing notes recorded slight swelling and a bruised right eye, and the night shift nurse notified the facility Medical Director. On 12/31/25, a physician’s assistant evaluated the resident for a fall follow-up and documented a positive review of systems for headache and vision changes, with a plan for an orbital x-ray. Despite this order, the resident’s electronic medical record contains no documentation that the orbital x-ray was ever completed or that any results were obtained. Subsequent nursing notes show that the resident later experienced another fall and was sent to a local emergency room, where a head CT was performed. On 2/10/26, the ADON confirmed that the resident did not receive the ordered orbital x-ray during the time the resident remained in the facility and stated that the x-ray should have been completed.
Failure to Promptly Notify Practitioner of Radiology Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of radiology results for one resident. The resident’s x-ray was performed on 1/5/26 at 6:37 PM, and the radiology report indicates the results were reported to the facility on 1/6/26 at 1:43 AM. The nurse practitioner ultimately reviewed the results on 1/6/26 at 4:59 PM. The facility’s nursing schedule shows that an RN and an LPN were assigned to the resident’s hall when the x-rays were ordered and when the results were received. The LPN reported checking the resident’s electronic medical record for updated x-ray results around 3:30 AM on 1/6/26 and stated that at that time the results still appeared as pending. The LPN did not check again for updated x-ray results for the remainder of the shift, despite being instructed that nurses should check for results at the end of each shift and notify the nurse practitioner immediately when results are received. The RN later documented in a nurse’s note on 1/6/26 at 5:30 PM that the x-ray results were relayed to the nurse practitioner, who then ordered the resident sent to the local hospital for further evaluation and treatment. However, the nurse practitioner stated that no facility staff notified them that the x-ray results had been uploaded prior to their own review at 4:59 PM on 1/6/26, and that earlier notification would have resulted in the resident being sent to the hospital earlier in the day. The Director of Nursing confirmed that the facility’s expectation is that nurses check for x-ray results at the beginning and end of their shifts and notify the nurse practitioner by call, text, or in person when results are available, to ensure the practitioner receives and reviews them.
Failure to Timely Complete Stat X-Ray Order After Resident Fall
Penalty
Summary
The facility failed to ensure that a physician’s stat order for an x-ray was completed within the facility’s required timeframe for one resident following a fall. The facility’s policy titled “Stat Orders,” last reviewed on 1/8/2025, required that stat orders be completed promptly within a four to six-hour timeframe. After a fall event, a Change of Condition/Interact assessment form dated 1/1/2026 at 7:40 p.m. documented that a resident’s roommate activated the call light to report that the resident was on the floor mat, having fallen on his back while returning from the bathroom. The RN Supervisor assessed the resident, who reported left wrist pain rated 3/10, and notified the physician and responsible party. The physician returned the call on 1/1/2026 at 7:45 p.m. and ordered a left wrist x-ray and Tylenol 325 mg for pain, which the RN Supervisor documented as noted and carried out. However, the survey findings concluded that the stat x-ray order was not completed timely in accordance with the facility’s policy. The resident involved had been originally admitted with diagnoses including diverticulosis of the large intestine without perforation or abscess, asthma, and unspecified abnormalities of gait and mobility, and had severely impaired cognition with a need for moderate to maximal assistance for toileting, bathing, dressing, personal hygiene, and mobility. The deficiency was cited for failure to complete the stat x-ray order within the required four to six-hour timeframe following the fall.
Failure to Complete Ordered Diagnostic Ultrasound
Penalty
Summary
Facility nursing staff failed to follow a physician’s order to obtain a right upper quadrant ultrasound for a resident whose laboratory tests showed elevated liver enzymes. The resident’s medical record showed that in September 2025 labs revealed elevated liver enzymes, and on 9/18/2025 the physician ordered a right upper quadrant ultrasound. Subsequent review of the medical record revealed no evidence that the ultrasound was completed or that results were obtained. During an interview, the Director of Nursing confirmed that nursing staff did not complete the ordered ultrasound, and the surveyor identified this as a concern related to failure to follow a physician’s order. The deficiency was identified during a complaint survey initiated after a complaint alleging the facility failed to monitor the resident’s status and well-being during the stay. Medical record review on 1/12/26 confirmed the absence of ultrasound results despite the prior order, and the DON’s interview on 1/12/25 further verified that the ordered diagnostic test was not carried out by nursing staff.
Failure to Ensure Completion and Follow-Up of Ordered X-Ray
Penalty
Summary
The facility failed to ensure that a resident received radiology services as ordered by the physician. A physician progress note dated 12/07/25 documented that the resident had a Stage 3 sacral pressure injury that appeared necrotic, and the physician ordered an x-ray of the sacrum and pelvis to evaluate for osteomyelitis. A corresponding physician order dated 12/07/25 directed staff to obtain an x-ray of the pelvis and sacrum. Review of the medical record from 12/07/25 through 12/15/25, when the resident was transferred to the hospital for evaluation, showed no documentation that the ordered x-ray had been completed. Nurse #2 reported that the physician saw the resident late in the evening on 12/07/25 and ordered the sacrum and pelvis x-ray, and that she entered the x-ray order into the radiology provider’s computer portal that same day. She stated the x-ray was not completed before the end of her shift and she was unaware it had not been done. The medical record contained no evidence that nursing staff followed up on the x-ray to determine if or when it was conducted or to obtain and report results to the physician. The DON stated that non-STAT x-rays may take a few days to be completed and reported that the radiology provider later indicated they had cancelled the x-ray because they did not have a credentialed radiologist to read the results, and that the provider did not inform facility staff of this cancellation. The DON stated it was her expectation that x-rays be obtained as ordered by the physician.
Failure to Notify Physician of Abnormal Lab and Diagnostic Results
Penalty
Summary
The facility failed to verify receipt or follow up with the attending physician or nurse practitioner regarding abnormal laboratory and diagnostic results for a resident who exhibited signs of infection. The resident, who had a history of chronic obstructive pulmonary disease, emphysema, respiratory failure with hypoxia, recurrent pneumonia, and aneurysm, was admitted with significant cognitive impairment and was dependent on staff for all care. Orders were placed for a chest x-ray and laboratory tests due to respiratory symptoms, and results showed an elevated white blood cell count and abnormal chest x-ray findings suggestive of an infectious process. Despite these abnormal findings, there was no documented evidence that the physician or nurse practitioner was notified of the results. The results were faxed and texted by the RN to the nurse practitioner and physician, but there was no confirmation of receipt or response. Interviews revealed that the nurse did not verify whether the results were received and did not follow up with the physician. The physician and nurse practitioner both stated they never received the results, and the facility did not have the correct contact information for text communication. The facility's policy required direct communication and documentation of physician notification, especially in cases of significant change in condition, but this was not followed. The lack of communication and verification resulted in the resident not receiving necessary medical intervention for the abnormal findings. The resident subsequently experienced a significant decline, was found unresponsive, and was pronounced deceased. There was no documentation of a change in condition report or assessment related to the abnormal laboratory or diagnostic results, and the required notification procedures were not followed as outlined in the facility's policies.
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