Failure to Complete Physician-Ordered CAT Scan After Resident Injury
Penalty
Summary
A physician order for a CAT scan was not completed for a resident who had sustained direct trauma to the forehead during a transfer with a mechanical lift. The resident, who had a history of falls and a fractured right femur, was on antiplatelet therapy and was observed with faded bruising around her right eye and a dark red/purple bruise on her right cheekbone. Documentation indicated that the resident was struck on the forehead by the lift's weight mechanism, resulting in a large hematoma and periorbital ecchymosis. A physician subsequently ordered a CAT scan of the head and face due to these injuries. Record review did not show any results for the ordered CAT scan, and interviews with facility staff confirmed that the scan had not been completed as ordered. The facility's policy required timely submission and scheduling of physician-ordered diagnostic tests, but this process was not followed in this instance, resulting in the failure to provide the ordered diagnostic service.