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:
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.
Delayed Completion of Ordered Arterial and Venous Ultrasounds: A resident with severe cognitive impairment, PVD, prior CVA, and an above-knee amputation had ordered arterial and venous ultrasounds that were not completed as scheduled. RN3 stated the tests were done a day late, and the DON noted there was no documentation of a follow-up call to the ultrasound provider or communication to the ordering practitioner about the missed timing.
Failure to obtain ordered STAT x-ray for a resident with dementia and a recent fall led to delayed imaging of a painful, bruised right arm. Nursing documented acute pain, bruising, and guarding, and a STAT x-ray was ordered and confirmed, but the x-ray provider did not come to the facility and staff did not follow up during the shift or after report. The next day, the resident was sent to the ED, where imaging showed a closed fracture of the right distal radius.
A resident with cervical stenosis and severe neck and knee pain had an MRI of the cervical spine ordered by a pain specialist, but the facility failed to ensure the test was completed. Facility policy assigns licensed nurses responsibility for arranging ordered diagnostic tests and monitoring results, yet the MRI was not performed as scheduled on two separate occasions, and there was no documentation explaining the missed appointment. The scheduler reported not being informed that the initial MRI was not completed or that it had been rescheduled, resulting in the resident not receiving the ordered imaging.
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.
Delayed Completion of Ordered Arterial and Venous Ultrasounds
Penalty
Summary
The facility failed to implement a physician order for arterial and venous ultrasounds in a timely manner for one resident. The resident was originally admitted and later readmitted to the facility and had diagnoses including left leg above-knee amputation, peripheral vascular disease, cerebral infarction, and sepsis. A physician order dated 12/16/2025 indicated the resident was to have arterial and venous ultrasounds completed on 12/17/2025, but the tests were not done on that date. During interview, RN3 stated the ultrasounds were not completed on 12/17/2025 and were instead completed on 12/18/2025, and that licensed nursing staff should have communicated to the physician that the tests were not done as ordered. The DON stated all physician orders, including ultrasound orders, should be completed in a timely manner and that there was no documentation in the resident’s progress notes showing a follow-up call to the ultrasound provider about why the ordered tests were not completed as scheduled. The resident’s MDS indicated severely impaired cognition and dependence on staff for several activities of daily living, and the H&P stated the resident did not have the capacity to understand and make decisions but could make decisions for activities of daily living.
Failure to Obtain Ordered STAT X-ray for Resident With Arm Pain After Fall
Penalty
Summary
The facility failed to provide radiology services consistent with a physician’s order when a resident who had Alzheimer’s disease, dementia, lack of coordination, difficulty walking, and a history of falling developed acute pain and bruising in the right shoulder and arm after an unwitnessed fall. On the morning of 03/31/26, nursing documented visible quarter-size dark purple bruising to the right upper and lower arm, facial grimacing, and the resident saying “ouch” when the arm was touched. The physician ordered a STAT x-ray of the right shoulder and arm to rule out fracture, and the radiology provider confirmed the STAT order at 11:52 A.M. Nurse #2 stated she called the x-ray provider after obtaining the STAT order, but the provider did not come to the facility during her double shift, which ended at 11:00 P.M., more than 11 hours later. She acknowledged she did not call the x-ray provider back at any time during her shift to follow up on when the x-ray would be completed. She also told the oncoming night-shift nurse that the x-ray had not yet been done and needed follow-up. Nurse #5 stated she was informed during shift report that the STAT x-ray was still pending, but she did not call the x-ray provider to check on the status. The next morning, Nurse #3 informed the ADON that the x-ray provider still had not come to complete the STAT x-ray. Nurse #3 then contacted the physician and obtained an order to send the resident to the hospital ED for imaging. The medical record contained no documentation that nursing followed up with the x-ray provider after the order was placed. The hospital discharge summary showed the x-ray revealed a closed fracture of the right distal radius.
Failure to Ensure Completion of Ordered MRI for Resident With Severe Cervical Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered MRI of the cervical spine was obtained for a resident experiencing severe pain. The facility’s policy titled “Physician Notification of Laboratory/Radiology/Diagnostic Results” dated 12/2025 states that licensed nurses are responsible for notifying the laboratory of physician orders for testing and for monitoring receipt of test results so that prompt, appropriate action may be taken. A pain clinic progress note dated 3/19/26, signed by a pain specialist, documents that the resident, an older adult with cervical stenosis and right knee pain, reported severe cervical pain rated 10/10, with a range of 4–10, described as tender, exhausting, penetrating, miserable, and tiring, interfering with general activity, mood, walking, sleep, enjoyment of life, and relationships. The treatment plan included an MRI of the cervical spine without contrast. A subsequent pain clinic progress note dated 4/16/26 documents that the resident did not receive the MRI ordered on 3/19/26. On interview, the pain specialist’s medical assistant confirmed that at the 4/16/26 follow-up visit, the MRI had not been completed. A hospital X-ray technician reported that the resident was scheduled for MRI appointments on 4/9/26 and again the day before the 4/24/26 interview, but the resident did not show up for either appointment and therefore had not had the MRI. The social service director, identified as the scheduler, stated that they were not made aware that the resident did not receive the MRI on 4/9/26 and that there was no documentation explaining why the MRI was not done on that date. The social service director also stated they were not aware that the MRI had been rescheduled, resulting in the resident still not having received the ordered MRI.
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