Failure to Maintain and Communicate Diagnostic Test Results
Penalty
Summary
The facility failed to ensure that the results of a diagnostic ultrasound were maintained in the clinical record, reviewed by staff, and reported to the attending physician for one resident. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and paraplegia, reported genital pain to staff. A physician's order was placed for an ultrasound, which was performed on the same day. However, the results of the ultrasound were not included in the resident's clinical record, nor were they reviewed or communicated to the attending physician as required by facility policy. Interviews with staff revealed that the unit manager was unaware of the missing results until prompted by the surveyor and had not reviewed or reported the findings to the physician. The DON confirmed that results should be reviewed and reported the day they are received, but was not aware that this had not occurred for this resident. The facility's policy requires documentation of when, how, and to whom diagnostic information is provided, but this process was not followed in this instance.