Failure to Timely Complete Stat X-Ray Order After Resident Fall
Penalty
Summary
The facility failed to ensure that a physician’s stat order for an x-ray was completed within the facility’s required timeframe for one resident following a fall. The facility’s policy titled “Stat Orders,” last reviewed on 1/8/2025, required that stat orders be completed promptly within a four to six-hour timeframe. After a fall event, a Change of Condition/Interact assessment form dated 1/1/2026 at 7:40 p.m. documented that a resident’s roommate activated the call light to report that the resident was on the floor mat, having fallen on his back while returning from the bathroom. The RN Supervisor assessed the resident, who reported left wrist pain rated 3/10, and notified the physician and responsible party. The physician returned the call on 1/1/2026 at 7:45 p.m. and ordered a left wrist x-ray and Tylenol 325 mg for pain, which the RN Supervisor documented as noted and carried out. However, the survey findings concluded that the stat x-ray order was not completed timely in accordance with the facility’s policy. The resident involved had been originally admitted with diagnoses including diverticulosis of the large intestine without perforation or abscess, asthma, and unspecified abnormalities of gait and mobility, and had severely impaired cognition with a need for moderate to maximal assistance for toileting, bathing, dressing, personal hygiene, and mobility. The deficiency was cited for failure to complete the stat x-ray order within the required four to six-hour timeframe following the fall.
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