Missing Signed and Dated Chest X-ray Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated chest x-ray report in the clinical record of a resident who was being treated for pneumonia. The resident, who had a history of chronic respiratory failure with hypoxia, transient cerebral ischemic attack, and chronic obstructive pulmonary disease, was admitted with these diagnoses and subsequently received two different antibiotics for infectious pneumonitis and pneumonia. Documentation in the medical record included orders for Amoxicillin-Potassium Clavulanate and Doxycycline, as well as nursing notes referencing the treatment for pneumonia. Despite the clinical indications and treatment for pneumonia, a review of the resident's medical record revealed that the chest x-ray report, which would have confirmed the diagnosis, was not present in the file. Interviews with nursing staff and the regional nurse consultant confirmed that a chest x-ray would have been ordered to support the diagnosis, but the report was not located in the record at the time of review. The absence of a signed and dated radiological report in the resident's clinical record constituted the deficiency.