Delay in STAT Chest X-ray Order and Completion
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a STAT (immediate) chest x-ray was ordered and completed as directed by a physician assistant for a resident with a history of acute on chronic diastolic heart failure, edema, paroxysmal atrial fibrillation, and acute embolism and thrombosis of the lower extremities. The resident was re-admitted with these diagnoses and was noted to have intact cognition. During a physician assessment, the resident reported increased weakness, fatigue, joint pain, dysuria, urinary urgency and frequency, and shortness of breath. The assessment included diminished breath sounds with crackles, trace bilateral lower extremity edema, and a plan to check a STAT chest x-ray due to suspected decompensated congestive heart failure. Despite the provider's documented plan for an immediate chest x-ray, a review of the physician orders revealed that the order for the STAT chest x-ray was not implemented until more than a week later. Interviews with the unit nurse manager indicated that the responsibility for entering new orders typically fell to the floor nurse or unit manager, but in this case, the order was not entered promptly, possibly due to a failure in the electronic medical system notification process. No further explanation or documentation was provided for the delay in implementing the STAT chest x-ray order.