Failure to Timely Implement STAT X-ray Order Due to Communication Breakdown
Penalty
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.