Failure to Schedule Physician-Ordered MRI
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician-ordered MRI was scheduled and completed for a resident. The resident, who was admitted with diagnoses including aphonia, dysarthria, and anarthria, had intact cognitive skills and required supervision to extensive assistance with activities of daily living. The resident's neurology appointment resulted in an order for an MRI of the thoracic and lumbar spine, as documented in the After Visit Summary. Despite the physician's order, the MRI was not scheduled, which was confirmed during an interview and record review with the Director of Nursing. The facility's policy required that diagnostic service orders be promptly carried out as instructed by the physician, but this was not followed, resulting in a delay in the resident's diagnostic testing.
Plan Of Correction
F684 How corrective actions will be accomplished for those residents found to have been affected by the deficient practice: On July 9, 2025, the Facility Case Manager promptly followed-up on MRI appointment for Resident 3 to prevent any further delays in diagnosis and treatment. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On July 10, 2025, the Medical Records Supervisor/designee conducted a review of all appointments within the previous 30 days to ensure appropriate follow-up was documented and completed, preventing any delays in diagnosis or treatment. No further concerns were reported or identified during this review. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur: From July 10, 2025, to July 11, 2025, licensed nursing staff participated in an in-service training conducted by the Director of Nursing (DON)/designee. The training emphasized the importance of appropriate follow-up related to documentation and communication with outside providers after each resident appointment, ensuring continuity of care and timely interventions. A one-on-one in-service was conducted by the DON on July 9th, 2025, with the Facility Case Manager to reinforce the timely scheduling of resident appointments as required and the appropriate communication of follow-up appointments. Any negative findings or barriers will be reported to the Administrator for further review and appropriate action. How the facility plans to monitor its performance to make sure that solutions are sustained: The Administrator/designee will provide any pattern of negative findings to QAPI committee monthly for 3 months for further monitoring and action planning as indicated or until QAA committee determines compliance. Date of Compliance: July 11th, 2025