Failure to File Signed and Dated Diagnostic Report in Resident Record
Penalty
Summary
A deficiency was identified when the facility failed to file a signed and dated report of a radiological diagnostic service in a resident's clinical record. The resident, who had a history of traumatic subdural hemorrhage with loss of consciousness, quadriplegia, spinal stenosis, and post-traumatic stress disorder, was admitted to the facility and later had a physician's order for an immediate (STAT) Kidney, Ureter, and Bladder (KUB) x-ray due to abdominal symptoms. Although nursing notes referenced the x-ray and its impression, the actual documentation of the x-ray results could not be located in the resident's medical record during the review period. Interviews with multiple staff members, including LPNs, the Regional Compliance Nurse, the DON, and the Administrator, revealed that the process for handling x-ray results involved receiving faxed reports from the x-ray company, notifying the physician, and distributing copies to various offices before forwarding the results to medical records for scanning and attachment to the resident's chart. However, there was a lack of clarity and consistency in the process, and the KUB x-ray result for the resident in question was not found in the clinical record as required.