Failure to Obtain Ordered Diagnostic Test for Resident with Edema
Penalty
Summary
A deficiency occurred when the facility failed to obtain a prompt diagnostic test, specifically a venous doppler scan, as ordered by a physician for a resident with multiple diagnoses including hemiplegia, hemiparesis following a stroke, breast and bone cancer, and heart failure. The resident was identified as having bilateral lower extremity edema, and a physician's order was placed for a doppler scan of the left lower extremity to investigate the cause of the edema. Although a physician's note later indicated that the doppler study was negative and attributed the edema to positional causes, there was no documentation in the resident's record that the doppler scan had actually been completed. During an interview, the facility administrator confirmed that the resident did not receive the ordered doppler scan and that the physician's note stating the test was negative was entered in error. The facility's policy requires that diagnostic tests be scheduled and performed according to physician orders, and that results be communicated to the ordering physician within a specified timeframe. The lack of documentation and failure to complete the ordered diagnostic test constituted a failure to follow both physician orders and facility policy.