Failure to Timely Implement STAT X-ray Order Due to Communication Breakdown
Summary
A deficiency occurred when a facility failed to ensure that a STAT x-ray order for a resident's left hand was implemented in a timely manner. The resident, who had diagnoses including dementia, a history of falls, and osteoporosis, was noted to have swelling in the left hand. The physician ordered an immediate x-ray, but the procedure was not completed as ordered. The radiology technician (RT) attempted to perform the x-ray but reported that the resident was combative and uncooperative. However, the RT did not inform facility staff that the x-ray could not be completed. The registered nurse (RN) who placed the order assisted the RT but was not told that the x-ray was unsuccessful. The RN attempted to follow up on the results later but was unable to reach the radiology company and was off duty the following day. It was only two days later that the facility became aware that the x-ray had not been performed. Facility policy required that diagnostic services, including STAT x-rays, be available at all times and that orders be promptly carried out as instructed by the physician. The failure to communicate the unsuccessful attempt and to follow up within the expected timeframe resulted in the resident not receiving the ordered diagnostic service in a timely manner.
Plan Of Correction
Immediate Action: Resident 1 was discharged to the hospital on 6/9/25. On 6/9/25, the D.O.N provided 1:1 inservice training and re-education to R.N. 1 with emphasis on availability and timeliness of clinical laboratory and radiology services to meet the needs of the residents provided by the facility. On 6/9/25, the facility notified the Diagnostic lab account executive of the importance of communication with the facility Licensed Staff if a Radiology Technician is unable to get an x-ray. On 6/10/25, an x-ray of the left wrist was performed at the hospital indicating no acute osseous or soft tissue abnormality; osteopenia. **Identification Of Others at Risk:** On 6/9/25, the DON reviewed all current lab/radiology orders to ensure timeliness of services to meet the needs of residents. No other residents were identified with the same deficient practice. **Process to Prevent Recurrence:** On 6/9/25 and 6/24/25, the DON provided inservices to Licensed Nurses (RN, LVN) to reinforce the facility's policy and procedure of availability of diagnostic, clinical laboratory, and radiology services to meet the needs of the residents provided by the facility. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. **Monitoring Process:** The DON will conduct random weekly audits on 5 residents for 4 weeks and then randomly for 3 months to ensure orders for clinical laboratory and radiology services are met in a quality and timely manner. The DON will report the findings to the QAPI committee monthly for further recommendations and resolutions for 3 months. Completion date: 6/24/25. **Identification Of Others at Risk:** On 6/9/25, the DON reviewed all current lab/radiology orders to ensure timeliness of services to meet the needs of residents. No other residents were identified with the same deficient practice. **Process to Prevent Recurrence:** On 6/9/25 and 6/24/25, the DON provided inservices to Licensed Nurses (RN, LVN) to reinforce the facility's policy and procedure of availability of diagnostic, clinical laboratory, and radiology services to meet the needs of the residents provided by the facility. Orders for diagnostic services will be promptly carried out as instructed by the physician's order. **Monitoring Process:** The DON will conduct random weekly audits on 5 residents for 4 weeks and then randomly for 3 months to ensure orders for clinical laboratory and radiology services are met in a quality and timely manner. The DON will report the findings to the QAPI committee monthly for further recommendations and resolutions for 3 months. Completion date: 6/24/25.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Delayed Stat X-Ray After Resident Fall: A resident with dementia, epilepsy, a history of falls, and severe cognitive impairment slid from bed and later developed left foot pain and swelling after landing on the foot with full body weight. The physician ordered a stat x-ray, but the imaging was not completed until the next morning, and the DON stated the delay exceeded the usual 4-hour timeframe and that the physician was not notified of the delay.
A resident with cancer, hip fracture, and anxiety disorder developed fever, shivering, and low O2 sat, and the MD ordered labs plus a chest x-ray. Nursing documented the order was sent to the x-ray vendor, but the record showed no evidence the x-ray was completed, and there was no documented follow-up when it was missed. The resident later became confused and uncontrollably shaky, was transferred to the hospital, and was admitted with pneumonia.
A resident with pulmonary fibrosis and CHF had an abnormal chest x-ray, and an NP ordered an outpatient chest CT with contrast. The CT was not scheduled in a timely manner, no CT results were found in the chart, and staff interviews confirmed the appointment had been missed and the scheduler had not arranged it until later. The DON and Regional RN also confirmed the results were unavailable, and the facility policy required timely submission of ordered radiology services.
A resident with increased weakness had a chest x-ray ordered after staff spoke with the NP, but the x-ray was not obtained when first ordered. Later, the resident’s guardian raised concern about the resident’s health status and possible change in condition, and another chest x-ray order was placed. The NHA confirmed the x-ray was not completed until nearly two weeks after the initial order.
A resident with dementia, gait impairment, weakness, and osteoporosis fell and complained of left hip pain. Staff ordered a hip x-ray, but it was not completed when expected, and the resident continued to have pain and difficulty moving the leg. The x-ray vendor said it was scheduled but had no time to come, and the resident was later sent to the hospital where a left hip fracture was diagnosed. The DON could not explain why the x-ray was not obtained or provide evidence of follow-up documentation.
A resident experienced a fall, was found on the floor with a left elbow skin tear, and later reported significant left hip pain with inability to tolerate ROM. An NP ordered a STAT hip X-ray and indicated that STAT imaging should occur within four hours, with nursing responsible for contacting radiology. The assigned RN initially entered the order as routine, later changed it to STAT, and called the X-ray company, but the physician orders did not reflect STAT status. The X-ray was not performed until the following day, at which time imaging revealed an acute comminuted left femoral intertrochanteric fracture.
Delayed Stat X-Ray After Resident Fall
Penalty
Summary
The facility failed to provide radiology services in accordance with a physician’s stat order for one resident after a fall. The resident was admitted with diagnoses including a right arm fracture, epilepsy, dementia, and a history of falling, and had severely impaired cognition with dependence on staff for multiple activities of daily living. After staff found the resident sitting on a landing pad beside the bed, the resident later reported left foot pain rated 4 out of 10, and swelling was noted to the left dorsal foot during skin assessment. The resident’s physician was notified and a stat x-ray of the left foot was ordered at 4:21 p.m. The radiology study was not completed until the next morning at 9:49 a.m. The DON stated that stat x-rays should typically be completed within four hours and that if not completed in that timeframe, nursing staff should notify the physician; however, that notification was not completed for this resident. The facility’s policy stated that diagnostic services are to be promptly carried out as ordered and that emergency requests must be labeled stat to assure prompt action.
Missed Chest X-Ray Order for Febrile Resident
Penalty
Summary
The facility failed to ensure that a chest x-ray ordered for a resident with fever was obtained in a timely manner. The resident had diagnoses including cancer, hip fracture, and anxiety disorder, and the admission MDS documented a BIMS score of 11, indicating moderate cognitive impairment. On 03/09/2026, the resident was observed flushed, shivering, febrile at 101.9 degrees Fahrenheit, with elevated blood pressure and an oxygen saturation of 92% on room air. The physician was notified and ordered blood work, urinalysis, urine culture and sensitivity, and a chest x-ray. A physician order documented a chest x-ray to be obtained that night, and nursing notes later documented that laboratory results were pending, with abnormal urinalysis and blood test results reviewed with the physician. A physician assistant later documented that the resident was awake, alert, and oriented to person and place with periods of forgetfulness, denied respiratory and urinary symptoms, and had stable respiratory status, while noting that chest x-ray and urine culture and sensitivity results would be followed up for further intervention. However, the medical record contained no evidence that the chest x-ray was completed as ordered. The resident later developed shaking uncontrollably and confusion, and the family requested transfer to the hospital, where the resident was admitted with pneumonia. Interviews with nursing leadership and the x-ray vendor indicated the requisition had been sent, but the vendor could not locate it and there was no documentation of follow-up in the medical record regarding the missed x-ray. The Director of Nursing stated the x-ray was not done and that the order should have been completed within 24 hours, but no progress notes documented the communication with the physician or the vendor regarding the missed test.
Delayed CT Scheduling and Missing Results
Penalty
Summary
The facility failed to schedule a CT scan and obtain the results in a timely manner for one resident with pulmonary fibrosis and congestive heart failure. The resident was admitted with diagnoses including pulmonary fibrosis and CHF, and the care plan addressed altered respiratory status and difficulty breathing with interventions to obtain and monitor labs and diagnostic work as ordered. After a chest x-ray showed interstitial nodular fibrosis, the NP assessed the resident and ordered an outpatient chest CT with contrast, but there were no CT results in the medical record. During interviews, the NP confirmed he ordered the CT after the abnormal chest x-ray and stated he did not know the CT had not been performed until later; he said he would have re-assessed the resident if staff had notified him the test could not be completed sooner. The DON and Regional RN confirmed the CT results were not available in the record, and the Regional RN stated nursing expected to call for results if they were not received within 48 hours. The transporter/scheduler confirmed the CT appointment had been missed and that he had not called to schedule the CT until later, stating he had only recently learned how to run the order report to identify appointments needing scheduling. The facility policy required nurses to submit timely requests for practitioner-ordered services, including radiology.
Delayed Chest X-Ray for Resident With Increased Weakness
Penalty
Summary
The facility failed to ensure that an x-ray was obtained in a timely manner for one resident who was noted to have increased weakness. On March 13, 2026, staff spoke with the nurse practitioner about the resident’s condition and received an order for a chest x-ray, but the x-ray was not obtained at that time. Later, on March 24, 2026, the resident’s guardian expressed concern about the resident’s health status and possible change in condition, and the nurse practitioner again ordered a chest x-ray to be completed on March 25, 2026. The Nursing Home Administrator confirmed in interview that the chest x-ray ordered on March 13, 2026, was not obtained until March 25, 2026.
Failure to Obtain Ordered X-Ray After Fall
Penalty
Summary
The facility failed to provide or obtain radiology services to meet the needs of a resident who sustained a left hip fracture after a fall. The resident had diagnoses including dementia with psychotic disturbance, lack of coordination, muscle weakness, gait and mobility abnormalities, and osteoporosis, and had severe cognitive impairment with frequent pain documented on the MDS. After a witnessed fall, the resident complained of left hip pain that worsened with movement and was rated 4 out of 10, and the provider ordered a left hip x-ray and PRN medication. Clinical documentation showed ongoing pain and difficulty moving the left leg, but the x-ray was not completed when expected. A nurse note documented that staff could not find x-ray results in the system and that the mobile x-ray company said the study was ordered for that day but had no time for completion. The nurse then notified the NP, who ordered the resident sent out because of the left hip pain. The resident was admitted to the hospital and diagnosed with a left hip fracture. Interviews with staff showed no clear explanation for why the x-ray was not obtained. An LPN stated the resident had complained of pain and that the x-ray was ordered, while another LPN said the resident was not someone who complained and that the resident had 10 out of 10 pain when the aide reported it. The DON stated she would expect the x-ray to be done the same day and acknowledged she had no explanation for the failure to obtain it and could not produce evidence of follow-up documentation or a physical assessment after the fall.
Delay in STAT Hip X-Ray After Resident Fall With Hip Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely STAT hip X-ray for a resident following a fall. According to progress notes, the resident was found on the floor in front of his wheelchair in an upright sitting position with a skin tear to the left elbow in the early morning, and the NP and the resident’s wife were notified. Later that day, the NP documented that the resident reported left hip pain and was unable to participate in range of motion, and ordered a STAT hip X-ray. The NP stated that a STAT X-ray should be completed within four hours and that nursing staff are responsible for contacting the X-ray company. The DON and ADON confirmed that the X-ray was not performed until the following morning, and the ADON recalled the resident’s daughter questioning why it took until the next morning for the X-ray to be done. The RN assigned to the resident that day reported that the resident complained of pain rated 7/10 and that she initially entered the X-ray as a regular order, then changed it to STAT after being instructed by the NP and called the X-ray company to communicate the STAT status. Progress notes from the next morning show the nurse contacting the X-ray company for an estimated time of arrival, and the radiology report indicates that the hip X-ray results, showing an acute comminuted left femoral intertrochanteric fracture, were not reported until the next day. The physician orders show two one-time hip X-ray orders entered on the day of the fall, neither marked as STAT, despite the facility policy requiring the nurse who takes the order to execute it, including contacting radiology services as required.
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