Failure to Provide Timely MRI Results to Physician as Ordered
Penalty
Summary
The facility failed to ensure that a physician's recommendation was carried out as ordered for a resident who required follow-up on MRI results. The resident had an MRI of the brain and cervical spine performed, which indicated a possible mass in the neck area. The physician had recommended that the MRI results be brought to the next neurology clinic appointment. However, the MRI results were not available for review at the neurology appointment, as the results had not been provided to the ordering physician in a timely manner. Documentation showed that the MRI was completed, but the results were not uploaded to the resident's medical record until several months later, and the request for the MRI results was made long after the imaging was performed. Interviews with facility staff revealed that there was a lack of follow-up to ensure the MRI results were sent to the appropriate physician. The case manager did not retain documentation of the request for imaging results and did not verify whether the results were sent to the physician's office. Additionally, there was a language barrier with the summary visit report, which was written in Spanish, and the process for translation and follow-up was not consistently followed. The Director of Nursing and Administrator acknowledged that the expected process for handling physician orders and documentation was not adhered to in this case.