Failure to Ensure Timely Stat Imaging After G-Tube Reinsertion
Penalty
Summary
The facility failed to ensure timely and appropriate laboratory services for a resident who required a stat KUB X-ray following the reinsertion of a gastrostomy tube. After the resident removed her G-tube, nursing staff replaced it and obtained a stat order for imaging to confirm placement. Although the order was placed early in the morning, the imaging was not completed until late afternoon, well beyond the expected timeframe outlined in the facility's contract with the imaging provider. The contract specified that stat exams should be performed within 60 minutes of the call, but the actual imaging was completed over eight hours after the order was placed. Interviews revealed that the nurse responsible for the resident's care attempted to follow up with the imaging provider but did not document these actions in the medical record or the 24-hour report. The nurse also could not recall if the delay was reported to supervisory staff. The physician was not notified of the delay, and stated that if she had been informed by mid-morning, she might have directed the resident to be sent to the hospital for more timely intervention. The imaging provider confirmed that no follow-up calls were received from the facility regarding the stat order, and that earlier time slots for the exam were unsuccessful. Facility leadership, including the ADON and DON, stated that staff were expected to follow up with the imaging provider and escalate delays to supervisors and the physician. However, there was no evidence that these steps were taken. Additionally, the facility's policy on test results did not address procedures for stat orders, contributing to the lack of clear guidance for staff in urgent situations.