F0658

D

Failure to Complete STAT X-Ray Order After Resident Fall

Fremont, California Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The facility failed to follow a physician’s STAT order for diagnostic imaging after a resident fall, resulting in a delay of more than 10 hours before appropriate evaluation occurred. The resident, who had moderately impaired cognition per a BIMS score of 9 and required supervision or touching assistance with toileting transfers, was assisted to a bedside commode by a CNA. After toileting, the resident was unable to turn or walk back to bed and was assisted to the floor. The assigned nurse assessed the resident at that time, documented pain rated three out of ten, and administered Tylenol. Later in the afternoon, the evening-shift LVN observed non-verbal pain cues and increased swelling of the resident’s right ankle, administered additional Tylenol, and notified the physician.

At approximately 4:00 p.m., the physician ordered a STAT X-ray of both knees and the right ankle related to the fall and swelling, but the imaging was not completed during the LVN’s shift despite the nurse’s understanding that STAT orders should be completed within four hours. The night-shift LVN subsequently noted swelling, pain, and purple discoloration of the right ankle and found that the STAT X-ray still had not been performed. The resident continued to receive Tylenol for pain throughout the evening and night. The resident was ultimately sent to the emergency department after midnight, where hospital records later documented a fracture of the right tibia and fibula related to the fall. The DON stated that STAT orders were expected to be completed within four hours and that if this could not be achieved, the physician should be notified to determine if there was a significant change or need for hospital transfer, consistent with the facility’s policy on acute condition changes.