Delayed Implementation of Physician-Ordered CT Scan
Penalty
Summary
The facility failed to ensure that physician orders were followed in accordance with professional standards of care and facility policy for a resident who was admitted with multiple diagnoses, including a traumatic hemorrhage of the cerebrum and severe cognitive impairment. Upon admission, the resident had a physician order for a CT scan of the head to be completed within two weeks. However, the order for the CT scan was not entered into the system until 15 days after admission, despite the expectation that all orders and follow-up appointments for new admissions be entered on the day of admission. Interviews with facility staff, including the DON and Unit Secretary, confirmed that the CT scan order was present in the admission documents but was not processed in a timely manner. The Unit Secretary acknowledged the delay and stated that not entering orders on time could potentially result in delayed care. Review of facility policy indicated that nurses are responsible for gathering information and contacting outside services, such as diagnostic services, upon admission. The failure to timely implement the physician's order for a CT scan resulted in a delay of ordered care for the resident.