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F0776
D

Delayed CT Scan Resulted in Missed Timely Orthopedic Follow-Up

Sylmar, California Survey Completed on 05-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a timely computed tomography (CT) scan for one resident who had a right humeral neck fracture and muscle wasting. The CT scan was ordered by the orthopedic physician on 9/9/2024, with instructions for the resident to return to the orthopedic physician in one week with the scan results. However, the facility delayed requesting authorization for the CT scan until 10/9/2024, despite the order being received a month earlier. The business office was responsible for submitting authorizations for radiology services, but could not provide a reason for the delay in requesting authorization. Nursing notes indicated that the orthopedic follow-up appointment was cancelled due to the lack of a completed CT scan, and the resident was only able to attend the CT scan appointment on 10/21/2024, more than a month after the initial order. Interviews with facility staff, including the LVN, Business Office Manager, and DON, confirmed that the delay in obtaining the CT scan was due to the late submission of the authorization request. The DON acknowledged that radiology orders should be processed the same day they are received and that the delay in obtaining the CT scan was not appropriate. Facility policy required staff to process test requisitions and arrange for tests based on physician orders, but this was not followed in this case, resulting in a significant delay in diagnostic imaging and follow-up orthopedic care for the resident.

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