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:
A resident admitted with a pelvic fx had an unwitnessed fall and low O2 sat, prompting the MD to order a stat chest x-ray. The record did not show the x-ray was obtained, and staff interviews indicated stat imaging should have been completed the same day or within 4 to 6 hours, with the MD notified if it could not be done.
A resident with a history of intracerebral hemorrhage, stroke, hemiplegia, falls, and other significant diagnoses slid out of bed during care and was found on the floor. The resident had physician orders for X-rays of the face and C-spine, including a STAT order, but the radiology studies were not completed before transfer to the hospital. The DON said there were record-tracking problems during an ownership/EMR transition and that radiology canceled the X-ray, but no documentation was provided showing when or why the orders were discontinued.
Delayed STAT X-ray After Resident Fall: A resident with a history of falls, anticoagulant use, neuropathy, and an above-knee amputation rolled out of bed during repositioning and was ordered a STAT knee x-ray. Although the order was received shortly after midnight, staff did not contact the diagnostic provider when the technician failed to arrive within the expected 4 to 6 hour window, and the x-ray was not completed until late morning, showing a patella fracture.
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.
Failure to Obtain Ordered Stat Chest X-Ray
Penalty
Summary
The facility failed to ensure an ordered stat chest x-ray was obtained for a resident admitted with a diagnosis of pelvic fracture after an unwitnessed fall. Progress notes show the resident’s physician was notified on 3/1/26 that the resident had an unwitnessed fall and an oxygen saturation of 85 percent on room air; oxygen was applied and the saturation increased to 93 percent. The physician then ordered a stat chest x-ray, but the resident’s clinical record did not show that the x-ray was obtained on 3/1/26. During interviews, an RN stated that a stat x-ray was to be completed the day it was ordered and that if the x-ray technician could not come to the facility, the physician was to be notified. The DNS stated stat orders were to be obtained within four to six hours and that if they could not be obtained within that time, the physician was to be notified; the DNS also stated there was no x-ray obtained and no indication staff called the physician.
Failure to Complete Ordered X-Rays After Resident Fall
Penalty
Summary
The facility failed to ensure that ordered X-ray services were completed in a timely manner for one resident after a fall from bed during care. A CNA reported that while changing the resident’s brief and turning the resident to the other side of the bed, the resident slid out of bed and was found sitting on the floor between the bed and wall. The resident had been admitted with multiple diagnoses including intracerebral hemorrhage, muscle weakness, falls, cerebral infarction, hemiplegia and hemiparesis affecting the left dominant side, progressive vascular leukoencephalopathy, morbid obesity, glaucoma, an implantable loop recorder, and neuropathy, and had a BIMS score of 15/15 indicating cognitive intactness. The resident’s record showed physician orders for X-rays of the right side of the face and C-spine, including a STAT order, but the radiology tests were not completed before the resident was transferred to the hospital. During interview, the DON stated that during the facility’s transition in ownership and new EMR there were problems with records and tracking orders, and that the X-ray was canceled by radiology. The DON stated the nurse manager should keep up with resident orders, but did not provide documentation of when or why the X-rays were discontinued. The facility policy stated that resident medications, treatments, and plan of care must be in accordance with licensed physician orders and that the facility shall ensure physician orders are followed as entered into the medical chart.
Delayed STAT X-ray After Resident Fall
Penalty
Summary
The facility failed to ensure a STAT x-ray was obtained in a timely manner for a resident with low back pain, type I diabetes mellitus with diabetic neuropathy, long-term anticoagulant use, a left above-knee amputation, and anxiety disorder. The resident had intact cognition on the quarterly MDS, required substantial assistance with bed mobility, and was dependent on staff for toileting hygiene and transfers. The care plan identified the resident as having actual falls and being at risk for falls related to confusion, deconditioning, psychoactive medication use, and the amputation, with interventions to anticipate and meet needs and follow the fall protocol. After the resident rolled out of bed onto the floor mat during repositioning, the RN notified the on-call provider and received a STAT order for a right knee x-ray. The diagnostic provider received the order shortly after midnight, but the x-ray was not obtained until late morning, approximately 11 hours after the fall. The record did not show that staff contacted the diagnostic provider when the technician did not arrive within the expected 4 to 6 hour timeframe, and the provider was not notified of the delay. Interviews confirmed that the overnight nursing supervisor did not follow up when the STAT exam was overdue, and the x-ray later showed a mid-to-inferior patella pole fracture with distracted fragments.
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.
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